Provider Demographics
NPI:1932502408
Name:WILSON, TYLER NOELL
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:NOELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0 AVENUE D
Mailing Address - Street 2:BUILDING 364
Mailing Address - City:PERRY POINT
Mailing Address - State:MD
Mailing Address - Zip Code:21902-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:0 AVENUE D
Practice Address - Street 2:BUILDING 364
Practice Address - City:PERRY POINT
Practice Address - State:MD
Practice Address - Zip Code:21902-1003
Practice Address - Country:US
Practice Address - Phone:410-642-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD08238225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program