MEDICARE: WILSON PEDIATRIC THERAPY LLC

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	252Y00000X	Early Intervention Provider Agency	3201	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063734333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON PEDIATRIC THERAPY LLC

Provider Business Mailing Address
First Line	:	424 LEWIS HARGETT CIR # B-100
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-3688
Country	:	US
Telephone Number	:	859-475-4305
Fax Number	:	877-804-4492

Provider Business Practice Location Address
First Line	:	424 LEWIS HARGETT CIR # B-100
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-3688
Country	:	US
Telephone Number	:	859-475-4305
Fax Number	:	877-804-4492

Authorized Official
Title or Position	:	OWNER/SPEECH LANGUAGE PATHOLOGIST
Name	:	MRS. KRESTA LEIGH WILSON
Credential	:	M.S. CCC-SLP
Telephone Number	:	859-806-5717

Provider Enumeration Date	:	02/26/2010
Last Update Date	:	09/24/2020

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