Provider Demographics
NPI:1730204272
Name:WILSON, CHARLENE MARIE (PT)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 FALLINGWATER DR
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1148
Mailing Address - Country:US
Mailing Address - Phone:609-926-5056
Mailing Address - Fax:
Practice Address - Street 1:700 TOWN BANK RD
Practice Address - Street 2:
Practice Address - City:NORTH CAPE MAY
Practice Address - State:NJ
Practice Address - Zip Code:08204-4411
Practice Address - Country:US
Practice Address - Phone:609-898-8899
Practice Address - Fax:609-884-0427
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00984900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist