Provider Demographics
NPI:1871836684
Name:WAHLQUIST, MYLA S (PT)
Entity Type:Individual
Prefix:MRS
First Name:MYLA
Middle Name:S
Last Name:WAHLQUIST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 VILLAGE SQUARE BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-1271
Mailing Address - Country:US
Mailing Address - Phone:850-431-4445
Mailing Address - Fax:850-431-6231
Practice Address - Street 1:1425 VILLAGE SQUARE BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-1271
Practice Address - Country:US
Practice Address - Phone:850-431-4445
Practice Address - Fax:850-431-6231
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT62242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics