MEDICARE: MRS. TERILYN WILSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	2702	NC

General Provider Information

NPI Number	:	1336230564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERILYN WILSON OTR/L

Provider Business Mailing Address
First Line	:	7826 PENCE POND LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-2449
Country	:	US
Telephone Number	:	704-451-1481
Fax Number	:

Provider Business Practice Location Address
First Line	:	598 INDIAN TRAIL RD S STE 141
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-8689
Country	:	US
Telephone Number	:	704-975-7008
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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