Provider Demographics
NPI:1922412618
Name:WILSON, CLAY (LMT)
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 LEE ROAD
Mailing Address - Street 2:C201
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789
Mailing Address - Country:US
Mailing Address - Phone:904-591-9038
Mailing Address - Fax:
Practice Address - Street 1:1695 LEE ROAD
Practice Address - Street 2:C201
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789
Practice Address - Country:US
Practice Address - Phone:904-591-9038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA39687225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist