Healthcare Provider Details

I. General information

NPI: 1902240385
Provider Name (Legal Business Name): TRACY WILSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17620 REDLAND RD STE A
ROCKVILLE MD
20855-1245
US

IV. Provider business mailing address

17620 REDLAND RD STE A
ROCKVILLE MD
20855-1245
US

V. Phone/Fax

Practice location:
  • Phone: 301-869-7505
  • Fax: 301-869-7515
Mailing address:
  • Phone: 301-869-7505
  • Fax: 301-869-7515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number03971
License Number StateMD

VIII. Authorized Official

Name: MRS. TRACY WILSON
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: MS, OTR/L
Phone: 301-869-7505