Basic Information
| Provider Information | |||||||||
| NPI: | 1619142262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 N 56TH STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154358830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 551 W LANCASTER AVENUE | ||||||||
| Address2: | STAFFING PLUS | ||||||||
| City: | HAVERFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105254000 | ||||||||
| FaxNumber: | 6105266750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0C000608L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.