Individual
TINA WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT, CLT
Contact information
Practice address
15019 NW 5TH AVE, NEWBERRY, FL 32669-2828
(352) 494-4372
Mailing address
15019 NW 5TH AVE, NEWBERRY, FL 32669-2828
(352) 494-4372
Taxonomy
Speciality
Code
Description
License number
State
172M00000X
Mechanotherapist
Primary
MA31099
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C1960
BC/BS
—
Enumeration date
08/17/2010
Last updated
08/17/2010
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