Provider Demographics
NPI:1194998518
Name:WILSON, HEATHER (OTR/L)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 WINIFRED RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6396
Mailing Address - Country:US
Mailing Address - Phone:301-722-1460
Mailing Address - Fax:
Practice Address - Street 1:1 BAKER PL
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2824
Practice Address - Country:US
Practice Address - Phone:304-788-4200
Practice Address - Fax:304-788-6461
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV591225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD03070OtherSTATE LICENSE
WV591OtherSTATE LICENSE