Provider Demographics
NPI:1790908507
Name:CLAVECILLA, WILFREDO BERNARDO (PT)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:BERNARDO
Last Name:CLAVECILLA
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 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:3451 ERNEST W BARRETT PKWY NW STE 130
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5035
Practice Address - Country:US
Practice Address - Phone:770-422-5078
Practice Address - Fax:770-427-0688
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist