Provider Demographics
NPI:1699010025
Name:WILSON, PAMELA (OTR/L)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7367 SPOUT SPRINGS RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5519
Mailing Address - Country:US
Mailing Address - Phone:770-965-1861
Mailing Address - Fax:770-965-1863
Practice Address - Street 1:7367 SPOUT SPRINGS RD
Practice Address - Street 2:SUITE 125
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5519
Practice Address - Country:US
Practice Address - Phone:770-965-1861
Practice Address - Fax:770-965-1863
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
303501OtherNBCOT