Provider Demographics
NPI:1427536663
Name:WEATHERHOLT, WADE THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:THOMAS
Last Name:WEATHERHOLT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-7697
Mailing Address - Country:US
Mailing Address - Phone:270-745-0987
Mailing Address - Fax:270-745-0986
Practice Address - Street 1:5796 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-7546
Practice Address - Country:US
Practice Address - Phone:270-745-0987
Practice Address - Fax:270-745-0986
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist