Provider Demographics
NPI:1427792415
Name:WILSON, TOBIAS (OTR)
Entity type:Individual
Prefix:
First Name:TOBIAS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 FAWN HILL WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-7123
Mailing Address - Country:US
Mailing Address - Phone:831-332-7461
Mailing Address - Fax:
Practice Address - Street 1:4441 FAWN HILL WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-7123
Practice Address - Country:US
Practice Address - Phone:831-332-7461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKOT-198327225X00000X
CAOT-23618225X00000X
NVOT-2961225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist