Provider Demographics
NPI:1801527734
Name:WILSON, CHARLENE B
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4483
Mailing Address - Country:US
Mailing Address - Phone:347-551-6057
Mailing Address - Fax:
Practice Address - Street 1:2925 WEBB RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-4483
Practice Address - Country:US
Practice Address - Phone:347-551-6057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002590224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA061605834Medicaid
GA061605834OtherGEORGIA DRIVERS LICENSE