Provider Demographics
NPI:1275752669
Name:DEWILDE, MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5652 31ST ST
Mailing Address - Street 2:
Mailing Address - City:GRANTVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66429-9324
Mailing Address - Country:US
Mailing Address - Phone:785-286-4613
Mailing Address - Fax:
Practice Address - Street 1:3220 SW ALBRIGHT DR
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-4707
Practice Address - Country:US
Practice Address - Phone:785-478-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1401502225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant