Provider Demographics
NPI:1336348515
Name:WILSON, RICHARD C (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 N WEBER ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7532
Mailing Address - Country:US
Mailing Address - Phone:719-635-1999
Mailing Address - Fax:
Practice Address - Street 1:1715 N WEBER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7532
Practice Address - Country:US
Practice Address - Phone:719-635-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07102882Medicaid
CO07102882Medicaid