=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881876761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY MARIE WILSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2007
-----------------------------------------------------
Last Update Date | 12/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1485 INTERNATIONAL PKWY SUITES 2051
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-798-6035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1932 STARDUST DR
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33755-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-236-0097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 11778
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------