Healthcare Provider Details

I. General information

NPI: 1174566814
Provider Name (Legal Business Name): SANDRA H. WILSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 STATE ROUTE 37 UNIT 2
NEW FAIRFIELD CT
06812-5036
US

IV. Provider business mailing address

88 STATE ROUTE 37 UNIT 2
NEW FAIRFIELD CT
06812-5036
US

V. Phone/Fax

Practice location:
  • Phone: 203-313-3923
  • Fax: 203-312-0699
Mailing address:
  • Phone: 203-313-3923
  • Fax: 203-312-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003001
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: