Provider Demographics
NPI:1134812886
Name:WILSON, ELISABETH (PT)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E 141ST ST
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3524
Mailing Address - Country:US
Mailing Address - Phone:918-322-3884
Mailing Address - Fax:918-322-3875
Practice Address - Street 1:500 E 141ST ST
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-3524
Practice Address - Country:US
Practice Address - Phone:812-628-3060
Practice Address - Fax:918-322-3875
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
OK6306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic