Provider Demographics
NPI:1629033816
Name:WILSON, GEORGE STUART JR (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:STUART
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 DENEEN AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:OH
Mailing Address - Zip Code:45050-1058
Mailing Address - Country:US
Mailing Address - Phone:513-539-9396
Mailing Address - Fax:
Practice Address - Street 1:220 YANKEE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-1042
Practice Address - Country:US
Practice Address - Phone:513-360-0689
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-3622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer