Provider Demographics
NPI:1639112493
Name:WAHL, RAY (DPT)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:WAHL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 N NEWTOWN STREET RD STE 200
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2319
Practice Address - Country:US
Practice Address - Phone:484-420-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001784225100000X
PAPTO18231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2291958000OtherAMERIHEALTH
2116451OtherMAMSI
2291958000OtherAMERIHEALTH IBC
PAPT018231OtherPA LICENSE
DE10000037576Medicaid
2291958000OtherAMERIHEALTH/IBC
DEJ10001784OtherDE LICENSE
Q02420Medicare UPIN
DE012740F68Medicare ID - Type Unspecified
2291958000OtherAMERIHEALTH
DEG02378A22Medicare PIN