Provider Demographics
NPI:1942211610
Name:WILSON, LAURA (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 NIKOMAS WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3527
Mailing Address - Country:US
Mailing Address - Phone:321-676-4684
Mailing Address - Fax:321-725-9907
Practice Address - Street 1:368 NIKOMAS WAY
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-3527
Practice Address - Country:US
Practice Address - Phone:321-676-4684
Practice Address - Fax:321-725-9907
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 16884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist