Provider Demographics
NPI:1174945471
Name:WILSON, DONNA (OT/L)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 N MAY AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9031
Mailing Address - Country:US
Mailing Address - Phone:405-541-1078
Mailing Address - Fax:405-216-3380
Practice Address - Street 1:17200 N MAY AVE
Practice Address - Street 2:STE 200
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9031
Practice Address - Country:US
Practice Address - Phone:405-541-1078
Practice Address - Fax:405-216-3380
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK709225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist