Basic Information
| Provider Information | |||||||||
| NPI: | 1053555169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 S 9TH ST | ||||||||
| Address2: | STE 4 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460602631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655243946 | ||||||||
| FaxNumber: | 3177086496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 6TH AVE E | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354013207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057591211 | ||||||||
| FaxNumber: | 2053491162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 3029 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.