Provider Demographics
NPI:1649215450
Name:WILCOXSON, MITSUE ALICE (ATC, PT)
Entity Type:Individual
Prefix:MRS
First Name:MITSUE
Middle Name:ALICE
Last Name:WILCOXSON
Suffix:
Gender:F
Credentials:ATC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2229
Mailing Address - Country:US
Mailing Address - Phone:765-497-0849
Mailing Address - Fax:765-494-9899
Practice Address - Street 1:900 N UNIVERSITY ST
Practice Address - Street 2:B63 MACKEY ARENA, PURDUE UNIVERSITY
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2070
Practice Address - Country:US
Practice Address - Phone:765-494-1703
Practice Address - Fax:765-494-9899
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225100000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer