Provider Demographics
NPI:1659750172
Name:WISE, WILBERT JOHN III (PT, DPT)
Entity Type:Individual
Prefix:
First Name:WILBERT
Middle Name:JOHN
Last Name:WISE
Suffix:III
Gender:M
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 1:982 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4619
Mailing Address - Country:US
Mailing Address - Phone:502-708-2942
Mailing Address - Fax:502-708-2942
Practice Address - Street 1:931 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2215
Practice Address - Country:US
Practice Address - Phone:502-561-6431
Practice Address - Fax:502-561-6432
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist