Provider Demographics
NPI:1760654644
Name:WILSON, CAROL LYLE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LYLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13603 LYTLE LN
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-2978
Mailing Address - Country:US
Mailing Address - Phone:210-695-1446
Mailing Address - Fax:
Practice Address - Street 1:5101 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4801
Practice Address - Country:US
Practice Address - Phone:210-616-0100
Practice Address - Fax:210-592-5491
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209034224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant