Provider Demographics
NPI:1811027535
Name:WILSON, SUSAN ELAINE (OCCUPATIONAL THERAPI)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OCEANS WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:32118-5946
Mailing Address - Country:US
Mailing Address - Phone:386-795-5899
Mailing Address - Fax:
Practice Address - Street 1:1 OCEANS WEST BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-5946
Practice Address - Country:US
Practice Address - Phone:386-252-7837
Practice Address - Fax:386-252-0021
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLOT1289225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ8875OtherBCBS
FL880176200Medicaid
FL0717141600Medicaid