MEDICARE: LATRELL WADE

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
2	225100000X	Physical Therapist	CP051580T	IN

General Provider Information

NPI Number	:	1871463380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRELL WADE

Provider Business Mailing Address
First Line	:	1650 LYNDON FARM CT STE 300
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-5005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3052 BARDSTOWN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-3020
Country	:	US
Telephone Number	:	502-454-5544
Fax Number	:

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

Provider Enumeration Date	:	11/10/2025
Last Update Date	:	12/11/2025

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Directions to “ LATRELL WADE ” Practice Location

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