Provider Demographics
NPI:1427571363
Name:WAHL, AUDREY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WAHL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 ROOSEVELT AVE # A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-2129
Mailing Address - Country:US
Mailing Address - Phone:815-718-5644
Mailing Address - Fax:
Practice Address - Street 1:359 VILLAGE COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-3007
Practice Address - Country:US
Practice Address - Phone:512-819-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1289529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist