Provider Demographics
NPI:1962860585
Name:WILSON, EMILY KATHERINE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KATHERINE
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 1:222 AUBURN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6005
Mailing Address - Country:US
Mailing Address - Phone:207-200-6293
Mailing Address - Fax:
Practice Address - Street 1:222 AUBURN ST STE 103
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6005
Practice Address - Country:US
Practice Address - Phone:207-200-6293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1618225100000X
ME5842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist