Provider Demographics
NPI:1669933404
Name:WILSON, DEMETRIUS DANTE (COTA/L)
Entity type:Individual
Prefix:MR
First Name:DEMETRIUS
Middle Name:DANTE
Last Name:WILSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5485 PERKIOMEN AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606-3676
Mailing Address - Country:US
Mailing Address - Phone:610-779-3993
Mailing Address - Fax:
Practice Address - Street 1:5485 PERKIOMEN AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606-3676
Practice Address - Country:US
Practice Address - Phone:610-779-3993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003322L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant