Provider Demographics
NPI:1093231458
Name:WANDTKE, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:WANDTKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 NARROW LEAF CT
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:CENTERBURG
Practice Address - State:OH
Practice Address - Zip Code:43011-8314
Practice Address - Country:US
Practice Address - Phone:740-625-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA002942225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant