Provider Demographics
NPI:1144840208
Name:WILSON, STEVEN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12363 CARRIAGE STONE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-8416
Mailing Address - Country:US
Mailing Address - Phone:765-725-0096
Mailing Address - Fax:
Practice Address - Street 1:11011 VILLAGE SQUARE LN
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-4559
Practice Address - Country:US
Practice Address - Phone:317-827-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002533A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant