Provider Demographics
NPI:1831458413
Name:WILSON, TYLER G (DPT, OMPT)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT, OMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 CEDAR ST STE 203
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-2211
Mailing Address - Country:US
Mailing Address - Phone:517-409-4677
Mailing Address - Fax:517-798-5667
Practice Address - Street 1:2380 CEDAR ST STE 203
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-2211
Practice Address - Country:US
Practice Address - Phone:517-409-4677
Practice Address - Fax:517-798-5667
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist