Provider Demographics
NPI:1013061506
Name:WILSON, GRETCHEN ANN (MSOTRL)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:ANN
Other - Last Name:RAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOTR/L
Mailing Address - Street 1:7019 CLARK HILLS DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8677
Mailing Address - Country:US
Mailing Address - Phone:505-401-4235
Mailing Address - Fax:
Practice Address - Street 1:2400 UNSER BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3392
Practice Address - Country:US
Practice Address - Phone:505-401-4235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist