Provider Demographics
NPI:1184106460
Name:WILSON, REYNA FORBES (COTA/L)
Entity type:Individual
Prefix:MS
First Name:REYNA
Middle Name:FORBES
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:REYNA
Other - Middle Name:YARETH
Other - Last Name:FORBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:3134 WENDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-7271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3134 WENDELL BLVD
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:NC
Practice Address - Zip Code:27591-7271
Practice Address - Country:US
Practice Address - Phone:919-850-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131-001916224Z00000X
NC9831224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant