Basic Information
| Provider Information | |||||||||
| NPI: | 1275655276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | LYNNETTE MAUCK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5306 MANGROVE WAY | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454313533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407931845 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1390 KING TREE DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454051401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372780723 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225X00000X | OT. 006762 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 0119004314 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.