Provider Demographics
NPI:1538193412
Name:WILSON, DONNAH ANN (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:DONNAH
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5490 E EMERALD CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2055
Mailing Address - Country:US
Mailing Address - Phone:770-974-5431
Mailing Address - Fax:
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:SUITE 390
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:404-355-0069
Practice Address - Fax:404-355-6825
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT LICENSE 001570174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00885717BMedicaid
GA001570OtherGA OT LICENSE
GA001570OtherGA OT LICENSE