MEDICARE: MICHELLE WILDER PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	003773	KY

General Provider Information

NPI Number	:	1639113376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE WILDER PT

Provider Business Mailing Address
First Line	:	14007 HICKORY RIDGE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-5176
Country	:	US
Telephone Number	:	502-777-2965
Fax Number	:	502-742-5553

Provider Business Practice Location Address
First Line	:	2400 EASTPOINT PKWY STE 130
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-4154
Country	:	US
Telephone Number	:	502-962-2400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	12/16/2020

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Directions to “ MICHELLE WILDER PT” Practice Location

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