Provider Demographics
NPI:1093391617
Name:PELVIC WISDOM, LLC
Entity Type:Organization
Organization Name:PELVIC WISDOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-885-1661
Mailing Address - Street 1:222 AUBURN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6005
Mailing Address - Country:US
Mailing Address - Phone:207-200-6293
Mailing Address - Fax:
Practice Address - Street 1:222 AUBURN ST STE 103
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6005
Practice Address - Country:US
Practice Address - Phone:207-200-6293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1962860585Medicaid