Provider Demographics
NPI:1386955367
Name:WILSON, LORA LINN (PTA)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:LINN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 N COUNTY ROAD 600 W
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:IN
Mailing Address - Zip Code:47342-9339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8000 N COUNTY ROAD 600 W
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:IN
Practice Address - Zip Code:47342-9339
Practice Address - Country:US
Practice Address - Phone:765-358-3851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001901A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant