Provider Demographics
NPI:1104252741
Name:WILSON, DONNA MARDELLE (COTA)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARDELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17518 NE 134TH PL
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-2106
Mailing Address - Country:US
Mailing Address - Phone:425-881-1342
Mailing Address - Fax:
Practice Address - Street 1:17518 NE 134TH PL
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-2106
Practice Address - Country:US
Practice Address - Phone:425-881-1342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-14
Last Update Date:2013-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60355569224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant