Provider Demographics
NPI:1669786851
Name:WILSON, STEVEN CHRISTIAN (DPT)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:CHRISTIAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19518 S TRENT JONES DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-6045
Mailing Address - Country:US
Mailing Address - Phone:225-667-8989
Mailing Address - Fax:225-667-9554
Practice Address - Street 1:145 ASPEN SQUARE
Practice Address - Street 2:SUITE A
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726
Practice Address - Country:US
Practice Address - Phone:225-667-8989
Practice Address - Fax:225-667-9554
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3B923C610Medicare PIN