Basic Information
| Provider Information | |||||||||
| NPI: | 1700310935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S BELT W | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622202503 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 101 S BELT W | ||||||||
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| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622202503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182777700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2017 | ||||||||
| LastUpdateDate: | 04/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056011502 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 2016003715 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OTR3033 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.