Provider Demographics
NPI:1043916588
Name:WILSON, ANNIE MACAINE (PT, DPT)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:MACAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 NEWPORT LN APT 202
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4015
Mailing Address - Country:US
Mailing Address - Phone:330-569-4158
Mailing Address - Fax:
Practice Address - Street 1:27100 CEDAR RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-1109
Practice Address - Country:US
Practice Address - Phone:216-831-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist