Healthcare Provider Details

I. General information

NPI: 1578642690
Provider Name (Legal Business Name): CHRISTOPHER NEAL WILSON BS, OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

328 N MICHIGAN ST SUITE 200
SOUTH BEND IN
46601-1244
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1350
  • Fax: 574-647-1351
Mailing address:
  • Phone: 574-647-1842
  • Fax: 574-647-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: