Healthcare Provider Details

I. General information

NPI: 1700310935
Provider Name (Legal Business Name): THOMAS WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S BELT W
BELLEVILLE IL
62220-2503
US

IV. Provider business mailing address

101 S BELT W
BELLEVILLE IL
62220-2503
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056011502
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2016003715
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR3033
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: