Provider Demographics
NPI:1790154581
Name:WILSON, TONYA (PTA)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 WESTRIDGE PARC LN
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4207
Mailing Address - Country:US
Mailing Address - Phone:636-236-9577
Mailing Address - Fax:
Practice Address - Street 1:15822 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2212
Practice Address - Country:US
Practice Address - Phone:636-220-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116424225200000X
MO311679605310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility