Healthcare Provider Details

I. General information

NPI: 1407132657
Provider Name (Legal Business Name): SUE A WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 FRENCH RD
CHEEKTOWAGA NY
14227-3632
US

IV. Provider business mailing address

3 SHERWOOD CT
WEST SENECA NY
14224-3108
US

V. Phone/Fax

Practice location:
  • Phone: 716-668-8021
  • Fax: 716-668-8022
Mailing address:
  • Phone: 716-870-1433
  • Fax: 716-668-8022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number024993-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: