Provider Demographics
NPI:1679052617
Name:WEDGEWORTH, KATY
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:WEDGEWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S BONNER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2330
Mailing Address - Country:US
Mailing Address - Phone:903-589-9871
Mailing Address - Fax:
Practice Address - Street 1:1401 RICE RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3233
Practice Address - Country:US
Practice Address - Phone:903-561-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140818225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant