Provider Demographics
NPI:1962730416
Name:WYLDE, MICHELE (PT, ATC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:WYLDE
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WATERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:60556-0098
Mailing Address - Country:US
Mailing Address - Phone:815-264-8600
Mailing Address - Fax:331-431-5462
Practice Address - Street 1:125 NORTH CEDAR STREET
Practice Address - Street 2:
Practice Address - City:WATERMAN
Practice Address - State:IL
Practice Address - Zip Code:60556
Practice Address - Country:US
Practice Address - Phone:815-264-8600
Practice Address - Fax:815-264-8600
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.014036225100000X, 2251G0304X, 2251S0007X, 2251X0800X, 261QP2000X
IL070014036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty