Provider Demographics
NPI:1356509178
Name:WHEELER, SERENA J (MAE)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:J
Last Name:WHEELER
Suffix:
Gender:F
Credentials:MAE
Other - Prefix:
Other - First Name:SERENA
Other - Middle Name:J
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, AA
Mailing Address - Street 1:1542 COOPER DEARING RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-9810
Mailing Address - Country:US
Mailing Address - Phone:270-784-3438
Mailing Address - Fax:270-793-0770
Practice Address - Street 1:1542 COOPER DEARING RD
Practice Address - Street 2:
Practice Address - City:ALVATON
Practice Address - State:KY
Practice Address - Zip Code:42122-9810
Practice Address - Country:US
Practice Address - Phone:270-784-3438
Practice Address - Fax:270-793-0770
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2014-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200405079222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist