Provider Demographics
NPI:1912241357
Name:WILDES, KEVIN F (LPTA,CSCS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:F
Last Name:WILDES
Suffix:
Gender:M
Credentials:LPTA,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ROSEBURY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7558
Mailing Address - Country:US
Mailing Address - Phone:770-704-6307
Mailing Address - Fax:
Practice Address - Street 1:133 ROSEBURY DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7558
Practice Address - Country:US
Practice Address - Phone:770-704-6307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1633225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant