Provider Demographics
NPI:1720218811
Name:WILSON, ALEXANDER A (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 MORAINE ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91 MORAINE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4329
Practice Address - Country:US
Practice Address - Phone:303-669-8863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9861225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
251638OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY