Provider Demographics
NPI:1487615522
Name:WILSON, ELLEN B (PT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
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 1:3311 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14034-9779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14318 ROUTE 62
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:NY
Practice Address - Zip Code:14034-9788
Practice Address - Country:US
Practice Address - Phone:716-532-8129
Practice Address - Fax:716-532-9201
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008212-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10489845OtherCAQH
NYS14617Medicare UPIN
NY10489845OtherCAQH