Provider Demographics
NPI:1811602865
Name:WILSON, CHARLES WILLIAM (OTR/L)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:WILLIAM
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:98 W LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1071
Mailing Address - Country:US
Mailing Address - Phone:602-570-0162
Mailing Address - Fax:
Practice Address - Street 1:5815 W. UTOPIA RD.
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-806-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-006074225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist