Provider Demographics
NPI:1881764785
Name:WILSON, RAE (PT)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 PLANTERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-6181
Mailing Address - Country:US
Mailing Address - Phone:317-345-8263
Mailing Address - Fax:
Practice Address - Street 1:97 DOVER ST STE 200
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7356
Practice Address - Country:US
Practice Address - Phone:317-272-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000010223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05007942AOtherLICENSE#