Healthcare Provider Details

I. General information

NPI: 1912903394
Provider Name (Legal Business Name): ANGELA D WUEBBELS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 WOLF CREEK DR STE 200
SWANSEA IL
62226-2343
US

IV. Provider business mailing address

916 TALON DR STE 102
O FALLON IL
62269-1848
US

V. Phone/Fax

Practice location:
  • Phone: 618-239-9910
  • Fax: 618-239-9795
Mailing address:
  • Phone: 618-628-8211
  • Fax: 618-628-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: