Provider Demographics
NPI:1700801743
Name:WILSON, LILLIAN POWELL (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:POWELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 S ADAMS ST
Mailing Address - Street 2:FORT WORTH
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4406
Mailing Address - Country:US
Mailing Address - Phone:817-927-9525
Mailing Address - Fax:
Practice Address - Street 1:5601 BRIDGE ST
Practice Address - Street 2:FORT WORTH
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2384
Practice Address - Country:US
Practice Address - Phone:817-457-9850
Practice Address - Fax:817-457-9865
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist