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General NPI Number Information
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NPI Number | 1063734333
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Entity Type | Organization
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Legal Business Name | WILSON PEDIATRIC THERAPY LLC
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Dates
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Enumeration Date | 02/26/2010
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Last Update Date | 09/24/2020
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Provider Practice Location Address
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Address Line | 424 LEWIS HARGETT CIR # B-100
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City | LEXINGTON
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State | KY
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Zip | 40503-3688
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Country | US
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Telephone | 859-475-4305
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Fax | 877-804-4492
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Provider Business Mailing Address
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Address Line | 424 LEWIS HARGETT CIR # B-100
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City | LEXINGTON
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State | KY
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Zip | 40503-3688
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Country | US
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Telephone | 859-475-4305
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Fax | 877-804-4492
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Authorized Official
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Title or Position | OWNER/SPEECH LANGUAGE PATHOLOGIST
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Name | MRS. KRESTA LEIGH WILSON
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Credential | M.S. CCC-SLP
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Telephone | 859-806-5717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 3201
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License Number State | KY
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