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NPI Code Detail

MEDICARE: MRS. MICKENZIE FARRELL WILSON MS, OTR/L

MEDICARE: MRS. MICKENZIE FARRELL WILSON MS, 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
1225X00000XOccupational Therapist15-0549NV

General Provider Information

NPI Number : 1346631884
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MICKENZIE FARRELL WILSON MS, OTR/L
Provider Business Mailing Address
First Line : 1354 ROSSINI ST
Second Line :
City : HENDERSON
State : NV
Zip : 89052-5552
Country : US
Telephone Number : 702-292-8160
Fax Number :
Provider Business Practice Location Address
First Line : 366 E MESA VERDE LN
Second Line :
City : LAS VEGAS
State : NV
Zip : 89123-1812
Country : US
Telephone Number : 702-227-4477
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/05/2015
Last Update Date : 02/05/2015

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