Provider Demographics
NPI:1215133863
Name:WILSON, BARBARA BOOTH (ATC, LIC)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:BOOTH
Last Name:WILSON
Suffix:
Gender:F
Credentials:ATC, LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25317 TRADEWINDS DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-5563
Mailing Address - Country:US
Mailing Address - Phone:813-907-7414
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY CAMPUS MC 2038 SAINT LEO UNIVERSITY
Practice Address - Street 2:33701 ST RD 52
Practice Address - City:SAINT LEO
Practice Address - State:FL
Practice Address - Zip Code:33574
Practice Address - Country:US
Practice Address - Phone:352-588-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 1066174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist