Provider Demographics
NPI:1447986062
Name:WILSON, TYLER RAY (OTR/L)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 S XANTHUS PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-3812
Mailing Address - Country:US
Mailing Address - Phone:918-260-4613
Mailing Address - Fax:
Practice Address - Street 1:900 E AIRPORT RD
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-9082
Practice Address - Country:US
Practice Address - Phone:918-260-4613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5687225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty