Provider Demographics
NPI:1174707798
Name:WILSON, AMY ANN (PT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:HARLETON
Mailing Address - State:TX
Mailing Address - Zip Code:75651-0838
Mailing Address - Country:US
Mailing Address - Phone:903-387-0451
Mailing Address - Fax:
Practice Address - Street 1:3201 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5145
Practice Address - Country:US
Practice Address - Phone:903-236-4291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178368225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist