Provider Demographics
NPI:1396854915
Name:WILSON, KENNETH MONROE (MHO PT SCS ATC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MONROE
Last Name:WILSON
Suffix:
Gender:M
Credentials:MHO PT SCS ATC
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:730 JOACHIM ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1414
Mailing Address - Country:US
Mailing Address - Phone:636-208-8163
Mailing Address - Fax:
Practice Address - Street 1:1355 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-756-9900
Practice Address - Fax:573-756-9988
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO02273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist