Provider Demographics
NPI:1306623079
Name:WILSON, OLIVIA (PT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3557
Mailing Address - Country:US
Mailing Address - Phone:631-424-1100
Mailing Address - Fax:
Practice Address - Street 1:1619 RUGBY RD
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1534
Practice Address - Country:US
Practice Address - Phone:516-477-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CT14801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist