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General NPI Number Information
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NPI Number | 1790154581
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Entity Type | Individual
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Provider Name | TONYA WILSON PTA
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Gender | Female
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Dates
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Enumeration Date | 09/22/2015
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Last Update Date | 09/22/2015
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Provider Practice Location Address
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Address Line | 15822 CLAYTON RD
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City | ELLISVILLE
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State | MO
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Zip | 63011-2212
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Country | US
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Telephone | 636-220-1681
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Fax |
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Provider Business Mailing Address
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Address Line | 246 WESTRIDGE PARC LN
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City | ELLISVILLE
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State | MO
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Zip | 63021-4207
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Country | US
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Telephone | 636-236-9577
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 116424
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 311679605
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License Number State | MO
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