Basic Information
| Provider Information | |||||||||
| NPI: | 1982909263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680287914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029320747 | ||||||||
| FaxNumber: | 4029915685 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680287914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029320747 | ||||||||
| FaxNumber: | 4029915685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 1536 | SD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2962 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 47065477701 | 05 | NE | MEDICAID |