Provider Demographics
NPI:1104338003
Name:WILSON, ELIZABETH CONZEL (DPT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CONZEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:CAROLE
Other - Last Name:CONZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3201 CHERRY RIDGE ST STE D400
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 CHERRY RIDGE ST STE D400
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4820
Practice Address - Country:US
Practice Address - Phone:210-692-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1230366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist