Provider Demographics
NPI:1013149699
Name:WILSON, MARK A (OT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 W GERMAN ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-2135
Mailing Address - Country:US
Mailing Address - Phone:315-866-3330
Mailing Address - Fax:315-866-6546
Practice Address - Street 1:690 W GERMAN ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2135
Practice Address - Country:US
Practice Address - Phone:315-866-3330
Practice Address - Fax:315-866-6546
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014372-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist