Healthcare Provider Details

I. General information

NPI: 1285709642
Provider Name (Legal Business Name): MARY LYNN WILSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E FEDERAL ST. SUITE C
MIDDLEBURG VA
20117
US

IV. Provider business mailing address

PO BOX 893
MIDDLEBURG VA
20118-0893
US

V. Phone/Fax

Practice location:
  • Phone: 540-687-6565
  • Fax: 540-687-6585
Mailing address:
  • Phone: 540-687-6565
  • Fax: 540-687-6585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305004796
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: