Provider Demographics
NPI:1245802776
Name:WILSON, KRISTEN (PT, ATC, CLT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, ATC, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40208-1451
Mailing Address - Country:US
Mailing Address - Phone:502-637-9313
Mailing Address - Fax:502-635-6317
Practice Address - Street 1:215 CENTRAL AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1451
Practice Address - Country:US
Practice Address - Phone:502-637-9313
Practice Address - Fax:502-635-6317
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic