Provider Demographics
NPI:1710853031
Name:WILSON, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WILSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 W FOOTHILL BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3684
Mailing Address - Country:US
Mailing Address - Phone:800-741-1164
Mailing Address - Fax:
Practice Address - Street 1:1317 W FOOTHILL BLVD STE 130
Practice Address - Street 2:STE 130
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3684
Practice Address - Country:US
Practice Address - Phone:800-741-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist