Healthcare Provider Details

I. General information

NPI: 1962730416
Provider Name (Legal Business Name): MICHELE WYLDE PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W ADAMS ST
WATERMAN IL
60556-4000
US

IV. Provider business mailing address

PO BOX 98
WATERMAN IL
60556-0098
US

V. Phone/Fax

Practice location:
  • Phone: 815-264-8600
  • Fax: 331-431-5462
Mailing address:
  • Phone: 815-264-8600
  • Fax: 331-431-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number070.014036
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070.014036
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070.014036
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070014036
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.014036
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number070.014036
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: