Provider Demographics
NPI:1891412045
Name:WILSON- ALSTON, AUDREY (OTA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WILSON- ALSTON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 BROOKSONG CT
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-6100
Mailing Address - Country:US
Mailing Address - Phone:803-200-6328
Mailing Address - Fax:
Practice Address - Street 1:506 BROOKSONG CT
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-6100
Practice Address - Country:US
Practice Address - Phone:803-200-6328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC476224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant