Provider Demographics
NPI:1801922778
Name:WILSON, KATHRYN (PT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:YEARSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 15301
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-1301
Mailing Address - Country:US
Mailing Address - Phone:941-402-5827
Mailing Address - Fax:
Practice Address - Street 1:40 SARASOTA CENTER BLVD STE F103
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-9713
Practice Address - Country:US
Practice Address - Phone:941-479-9894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886990100Medicaid