MEDICARE: MRS. KELLY ELIZABETH WILSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	0119005041	VA

General Provider Information

NPI Number	:	1689903593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY ELIZABETH WILSON OTR/L

Provider Business Mailing Address
First Line	:	1522 MORRIS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-1217
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1522 MORRIS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-1217
Country	:	US
Telephone Number	:	248-342-3180
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/24/2009
Last Update Date	:	12/24/2009

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