Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 005173-1 | NY |
NPI | 1013219708 |
---|---|
Provider Name | Diane Wilson |
First Address | Maybrook, NY 12543-1126 |
Second Address | Maybrook, NY 12543-1126 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2010 |
Last Update Date | 01/12/2010 |