Provider Demographics
NPI:1760737381
Name:WILSON, CARLY M (PT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:M
Other - Last Name:KUNZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12325 ARIES LOOP S
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-5228
Mailing Address - Country:US
Mailing Address - Phone:512-797-5933
Mailing Address - Fax:
Practice Address - Street 1:1203 CALLAHAN AVE
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1724
Practice Address - Country:US
Practice Address - Phone:512-797-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1220196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist