Healthcare Provider Details

I. General information

NPI: 1285977462
Provider Name (Legal Business Name): WILSON PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 LEWIS HARGETT CIR # B-100
LEXINGTON KY
40503-3688
US

IV. Provider business mailing address

424 LEWIS HARGETT CIR # B-100
LEXINGTON KY
40503-3688
US

V. Phone/Fax

Practice location:
  • Phone: 859-475-4305
  • Fax: 877-804-4492
Mailing address:
  • Phone: 859-475-4305
  • Fax: 877-804-4492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number005311
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberR4342
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberKY 3472
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberKY 4155
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberKY 3597
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberKY 3201
License Number StateKY

VIII. Authorized Official

Name: KRESTA LEIGH WILSON
Title or Position: OWNER/MANAGER
Credential: M.S. CCC-SLP
Phone: 859-475-4305