Provider Demographics
NPI:1396923777
Name:WYATT, RACHEL THUNDER ROSE (PT, DPT, CLT)
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:THUNDER ROSE
Last Name:WYATT
Suffix:
Gender:F
Credentials:PT, DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 DUDLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662
Mailing Address - Country:US
Mailing Address - Phone:903-753-6635
Mailing Address - Fax:
Practice Address - Street 1:1200 DUDLEY ROAD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662
Practice Address - Country:US
Practice Address - Phone:903-753-6635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1179095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist