Provider Demographics
NPI:1699735423
Name:WILM, MARION ELLEN (OTR/L)
Entity type:Individual
Prefix:MS
First Name:MARION
Middle Name:ELLEN
Last Name:WILM
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 1:10516 PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8405
Mailing Address - Country:US
Mailing Address - Phone:704-541-9080
Mailing Address - Fax:704-542-0699
Practice Address - Street 1:10516 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8405
Practice Address - Country:US
Practice Address - Phone:704-541-9080
Practice Address - Fax:704-542-0699
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1830225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7388153Medicaid