Provider Demographics
NPI:1386281269
Name:LAUDERBACK, WESLEY CRAIG (MSPT)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:CRAIG
Last Name:LAUDERBACK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 GREENUP AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-1953
Mailing Address - Country:US
Mailing Address - Phone:606-324-0540
Mailing Address - Fax:606-324-0616
Practice Address - Street 1:8985 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1923
Practice Address - Country:US
Practice Address - Phone:740-456-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty