Provider Demographics
NPI:1760517585
Name:WILSON, MARY C (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 YORK RD
Mailing Address - Street 2:19
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-296-9195
Mailing Address - Fax:410-296-9197
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:19
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-296-9195
Practice Address - Fax:410-296-9197
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS9550001OtherBCBS FEDERAL
MD35184405OtherBLUE CROSS BLUE SHIELD
MDDA2862 P00046856OtherRAILROAD MEDICARE
MDS00422Medicare UPIN
MD928L412EMedicare ID - Type Unspecified