Provider Demographics
NPI:1962772202
Name:WILSON, SUSAN OSBORNE (OTR/L)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:OSBORNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ABBOTSBURY CT
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6529
Mailing Address - Country:US
Mailing Address - Phone:704-844-9065
Mailing Address - Fax:
Practice Address - Street 1:8919 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-9600
Practice Address - Country:US
Practice Address - Phone:704-556-3428
Practice Address - Fax:704-643-8026
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4012225X00000X
SC2308225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist