Provider Demographics
NPI:1790840296
Name:WILSON, TRACY
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 SAINT GEORGE WAY
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-3265
Mailing Address - Country:US
Mailing Address - Phone:301-570-8415
Mailing Address - Fax:301-570-8415
Practice Address - Street 1:2422 SAINT GEORGE WAY
Practice Address - Street 2:
Practice Address - City:BROOKEVILLE
Practice Address - State:MD
Practice Address - Zip Code:20833-3265
Practice Address - Country:US
Practice Address - Phone:301-570-8415
Practice Address - Fax:301-570-8415
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ917-0001OtherBCBS PROVIDER NUMBER