MEDICARE: MRS. TRACY WILSON

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	03971	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J917-0001	OTHER	MD	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1790840296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY WILSON

Provider Business Mailing Address
First Line	:	2422 SAINT GEORGE WAY
Second Line	:
City	:	BROOKEVILLE
State	:	MD
Zip	:	20833-3265
Country	:	US
Telephone Number	:	301-570-8415
Fax Number	:	301-570-8415

Provider Business Practice Location Address
First Line	:	2422 SAINT GEORGE WAY
Second Line	:
City	:	BROOKEVILLE
State	:	MD
Zip	:	20833-3265
Country	:	US
Telephone Number	:	301-570-8415
Fax Number	:	301-570-8415

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/08/2007

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Directions to “ MRS. TRACY WILSON ” Practice Location

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