Provider Demographics
NPI:1417405499
Name:WILDE, KENDALL E (DPT)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:E
Last Name:WILDE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8541 E ANDERSON DR STE 100
Mailing Address - Street 2:STE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5430
Mailing Address - Country:US
Mailing Address - Phone:480-585-6810
Mailing Address - Fax:480-585-6910
Practice Address - Street 1:1615 RIDENOUR BLVD NW STE 204
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4464
Practice Address - Country:US
Practice Address - Phone:770-580-8070
Practice Address - Fax:770-285-8751
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013169225100000X
AZ12414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT013169OtherPHYSICAL THERAPY LICENSE