MEDICARE: LAURA WILSON PT

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	225100000X	Physical Therapist	PT 16884	FL

General Provider Information

NPI Number	:	1942211610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA WILSON PT

Provider Business Mailing Address
First Line	:	368 NIKOMAS WAY
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-3527
Country	:	US
Telephone Number	:	321-676-4684
Fax Number	:	321-725-9907

Provider Business Practice Location Address
First Line	:	368 NIKOMAS WAY
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-3527
Country	:	US
Telephone Number	:	321-676-4684
Fax Number	:	321-725-9907

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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