Provider Demographics
NPI:1922279090
Name:WILSON, CYNTHIA ANN (OTA/L)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1779 N CONGRESS AVE # 398
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8205
Mailing Address - Country:US
Mailing Address - Phone:561-731-1975
Mailing Address - Fax:
Practice Address - Street 1:7273 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-1316
Practice Address - Country:US
Practice Address - Phone:561-543-5881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA544224Z00000X
FLOTA 544222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist