Provider Demographics
NPI:1023245263
Name:WILSON, EMILY ELAINE (MA, BA)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, BA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ELAINE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:560 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1572
Mailing Address - Country:US
Mailing Address - Phone:206-604-1476
Mailing Address - Fax:
Practice Address - Street 1:400 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6808
Practice Address - Country:US
Practice Address - Phone:541-613-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60089348225X00000X
OR249267225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist