Provider Demographics
NPI:1376656652
Name:WILTENS, SOFIA A (LPT)
Entity Type:Individual
Prefix:MRS
First Name:SOFIA
Middle Name:A
Last Name:WILTENS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:MRS
Other - First Name:SOFIA
Other - Middle Name:
Other - Last Name:AGGELAKI-WILTENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPT
Mailing Address - Street 1:1221 W BEN WHITE BLVD STE 211A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7095
Mailing Address - Country:US
Mailing Address - Phone:512-707-8392
Mailing Address - Fax:512-707-2841
Practice Address - Street 1:1221 W BEN WHITE BLVD STE 211A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7095
Practice Address - Country:US
Practice Address - Phone:512-707-8392
Practice Address - Fax:512-707-2841
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1062495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T0936OtherBCBS
TX8C2007Medicare PIN