Provider Demographics
NPI:1336504992
Name:WILDS, EMELY (PT)
Entity Type:Individual
Prefix:
First Name:EMELY
Middle Name:
Last Name:WILDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOLCOMB
Mailing Address - State:KS
Mailing Address - Zip Code:67851-9608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 N IBP RD
Practice Address - Street 2:
Practice Address - City:HOLCOMB
Practice Address - State:KS
Practice Address - Zip Code:67851-8902
Practice Address - Country:US
Practice Address - Phone:620-277-4379
Practice Address - Fax:620-277-4382
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist