Provider Demographics
NPI:1417122367
Name:WILDE, RAQUEL FESTEJO (PT)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:FESTEJO
Last Name:WILDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:PLAMENCO
Other - Last Name:FESTEJO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:8059 EAST PRAIRIE ROAD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:224-659-4652
Mailing Address - Fax:
Practice Address - Street 1:HEALTHPRO HERITAGE
Practice Address - Street 2:#1 MARCUS DRIVE STE 102
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-244-3626
Practice Address - Fax:864-501-4631
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist