Individual
STACEY A WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OT
Contact information
Practice address
2605 E CREEKS EDGE DR, BLOOMINGTON, IN 47401-8368
(812) 333-2663
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
31004123A
IN
225XH1200X
Hand Occupational Therapist
31004123A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
090540881
MEDICARE PTAN
IN
05
—
300081337
—
IN
Enumeration date
05/19/2023
Last updated
10/18/2023
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