Healthcare Provider Details

I. General information

NPI: 1700276946
Provider Name (Legal Business Name): ASHLY WILSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 PERRY AVE N
BROOKLYN CENTER MN
55429-1225
US

IV. Provider business mailing address

12517 RACHAEL DR
ROGERS MN
55374-2815
US

V. Phone/Fax

Practice location:
  • Phone: 763-585-7335
  • Fax:
Mailing address:
  • Phone: 612-817-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number104737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: