Provider Demographics
NPI:1972129492
Name:WILSON, BRE'ANNA MONIQUE (OTR)
Entity type:Individual
Prefix:
First Name:BRE'ANNA
Middle Name:MONIQUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 STEINER RANCH BLVD APT 21201
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-2561
Mailing Address - Country:US
Mailing Address - Phone:979-484-9499
Mailing Address - Fax:
Practice Address - Street 1:4800 STEINER RANCH BLVD APT 21201
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78732-2561
Practice Address - Country:US
Practice Address - Phone:979-484-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118216225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist