Provider Demographics
NPI:1205578069
Name:WILSON, MISSEY RENEE' (COTA)
Entity type:Individual
Prefix:
First Name:MISSEY
Middle Name:RENEE'
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W LUBBOCK ST
Mailing Address - Street 2:
Mailing Address - City:STREETMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75859-8120
Mailing Address - Country:US
Mailing Address - Phone:903-229-7139
Mailing Address - Fax:
Practice Address - Street 1:209 W LUBBOCK ST
Practice Address - Street 2:
Practice Address - City:STREETMAN
Practice Address - State:TX
Practice Address - Zip Code:75859-8120
Practice Address - Country:US
Practice Address - Phone:903-229-7139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211024224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant