Provider Demographics
NPI:1013996818
Name:WILSON, DAWN (PT)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8816 MANCHESTER RD
Mailing Address - Street 2:#318
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2602
Mailing Address - Country:US
Mailing Address - Phone:618-256-7962
Mailing Address - Fax:618-256-1660
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-6267
Practice Address - Fax:618-256-7931
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1042059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN