Provider Demographics
NPI:1023155033
Name:WILD, KAREN LYNN (MPT)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LYNN
Last Name:WILD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3488 JEFFCO BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-6015
Mailing Address - Country:US
Mailing Address - Phone:636-464-5439
Mailing Address - Fax:636-464-5438
Practice Address - Street 1:3488 JEFFCO BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6015
Practice Address - Country:US
Practice Address - Phone:636-464-5439
Practice Address - Fax:636-464-5438
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114477225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO483877411Medicaid