Provider Demographics
NPI:1992279368
Name:DE LEON, WILSON NUQUI (COTA)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:NUQUI
Last Name:DE LEON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:WILSON
Other - Middle Name:NUQUI
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:3703 W LAKE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1266
Mailing Address - Country:US
Mailing Address - Phone:847-998-1188
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE STE 200
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1266
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005076224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant