Basic Information
| Provider Information | |||||||||
| NPI: | 1790982288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | MAXINE | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2116 BLUE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352263132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059797806 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2204 LAKESHORE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | HOMEWOOD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058680147 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| 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 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 23442 | 01 | AL | BLUE CROSS | OTHER | 2108 | 01 | AL | AL STATE BOARD OF OT | OTHER |