Provider Demographics
NPI:1982215547
Name:WILSON, OLIVIA (PTA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14176 NATIONAL RD SW
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:OH
Mailing Address - Zip Code:43068-3363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:197 BARANOF E
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-1200
Practice Address - Country:US
Practice Address - Phone:614-715-3063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009898208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation