Provider Demographics
NPI:1285977462
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/MANAGER
Authorized Official - Prefix:
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:859-475-4305
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:2013-04-05
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0053112251P0200X
KYR4342225XP0200X
KYKY 3201235Z00000X
KYKY 3472235Z00000X
KYKY 4155235Z00000X
KYKY 3597235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100658910Medicaid