Provider Demographics
NPI:1841730355
Name:WILSON, MAGDALENA (ATC/L)
Entity type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WARREN WAY
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2113
Mailing Address - Country:US
Mailing Address - Phone:860-961-3251
Mailing Address - Fax:
Practice Address - Street 1:110 WOODBURY RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2130
Practice Address - Country:US
Practice Address - Phone:860-945-7713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0010452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer