MEDICARE: ALYSE ANN WIDGER DPT

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	225100000X	Physical Therapist	PT26514	FL
2	225100000X	Physical Therapist	PT024250	PA

General Provider Information

NPI Number	:	1104198431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSE ANN WIDGER DPT

Provider Business Mailing Address
First Line	:	1257 CARMONT DR
Second Line	:
City	:	MEADVILLE
State	:	PA
Zip	:	16335-2822
Country	:	US
Telephone Number	:	814-671-8353
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 CHESTNUT ST
Second Line	:
City	:	MEADVILLE
State	:	PA
Zip	:	16335-4404
Country	:	US
Telephone Number	:	814-547-6510
Fax Number	:	814-547-6511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2012
Last Update Date	:	08/09/2016

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