Provider Demographics
NPI:1720717903
Name:WILSON, TIERRA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 FELLOWSHIP RD STE 290
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3418
Mailing Address - Country:US
Mailing Address - Phone:856-424-5552
Mailing Address - Fax:856-424-5559
Practice Address - Street 1:523 FELLOWSHIP RD STE 290
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3418
Practice Address - Country:US
Practice Address - Phone:856-424-5552
Practice Address - Fax:856-424-5559
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA022211002251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology