Basic Information
| Provider Information | |||||||||
| NPI: | 1164778676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DARLA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6006 MAHONING AVE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | AUSTINTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445152239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307553000 | ||||||||
| FaxNumber: | 3305997008 | ||||||||
| Practice Location | |||||||||
| Address1: | 6006 MAHONING AVE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | AUSTINTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445152239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307553000 | ||||||||
| FaxNumber: | 3305997008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT013856 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.