Provider Demographics
NPI:1699855981
Name:WILSON, BRIAN TODD (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:TODD
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 CAMINO DEL RIO S STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3520
Mailing Address - Country:US
Mailing Address - Phone:619-501-2195
Mailing Address - Fax:619-501-2176
Practice Address - Street 1:16542 PROSPECT LN
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-4606
Practice Address - Country:US
Practice Address - Phone:858-752-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33609225100000X
FLPT 22916225100000X
COPTL0016742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist