Provider Demographics
NPI:1871130583
Name:WILSON, JUSTINE BREANNE (DPT)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:BREANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11811 N TATUM BLVD STE 3031
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1621
Mailing Address - Country:US
Mailing Address - Phone:602-708-8091
Mailing Address - Fax:602-218-6462
Practice Address - Street 1:11811 N TATUM BLVD STE 3031
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1621
Practice Address - Country:US
Practice Address - Phone:602-708-8091
Practice Address - Fax:602-218-6462
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60957709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist