Provider Demographics
NPI:1821174806
Name:WIDELO, DEBORAH LOUISE (PT, MS, PCS)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LOUISE
Last Name:WIDELO
Suffix:
Gender:F
Credentials:PT, MS, PCS
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 4561
Mailing Address - Street 2:340 GREENING LANE
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40392-4561
Mailing Address - Country:US
Mailing Address - Phone:859-749-9305
Mailing Address - Fax:859-737-3513
Practice Address - Street 1:340 GREENING LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391
Practice Address - Country:US
Practice Address - Phone:859-749-9305
Practice Address - Fax:859-737-3513
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003026225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYGP-206Medicaid