Healthcare Provider Details

I. General information

NPI: 1053555169
Provider Name (Legal Business Name): MARC DAVID WILSON OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 6TH AVE E
TUSCALOOSA AL
35401-3207
US

IV. Provider business mailing address

10 S 9TH ST STE 4
NOBLESVILLE IN
46060-2631
US

V. Phone/Fax

Practice location:
  • Phone: 205-759-1211
  • Fax: 205-349-1162
Mailing address:
  • Phone: 765-524-3946
  • Fax: 317-708-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3029
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: