MEDICARE: MS. SUSAN ELAINE WILSON OCCUPATIONAL THERAPI

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	222Q00000X	Developmental Therapist
2	225X00000X	Occupational Therapist	OT1289	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z8875	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811027535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN ELAINE WILSON OCCUPATIONAL THERAPI

Provider Business Mailing Address
First Line	:	1 OCEANS WEST BLVD
Second Line	:
City	:	DAYTONA BEACH SHORES
State	:	FL
Zip	:	32118-5946
Country	:	US
Telephone Number	:	386-795-5899
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 OCEANS WEST BLVD
Second Line	:
City	:	DAYTONA BEACH SHORES
State	:	FL
Zip	:	32118-5946
Country	:	US
Telephone Number	:	386-252-7837
Fax Number	:	386-252-0021

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	02/10/2022

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