Healthcare Provider Details

I. General information

NPI: 1952371577
Provider Name (Legal Business Name): SUZANNE B WILSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 OAKLAND PKWY
LEESBURG GA
31763-7201
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 229-420-1839
  • Fax: 229-483-0601
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT003661
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003661
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: