Provider Demographics
NPI:1063734333
Name:WILSON PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:WILSON PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRESTA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:859-806-5717
Mailing Address - Street 1:424 LEWIS HARGETT CIR # B-100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3688
Mailing Address - Country:US
Mailing Address - Phone:859-475-4305
Mailing Address - Fax:877-804-4492
Practice Address - Street 1:424 LEWIS HARGETT CIR # B-100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3688
Practice Address - Country:US
Practice Address - Phone:859-475-4305
Practice Address - Fax:877-804-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3201252Y00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100658910Medicaid