Provider Demographics
NPI:1932730504
Name:WILDE, ALYSSA (PT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12153 LAKE PLACID DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5112
Mailing Address - Country:US
Mailing Address - Phone:314-520-1376
Mailing Address - Fax:
Practice Address - Street 1:11988 MARK TWAIN LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2825
Practice Address - Country:US
Practice Address - Phone:314-291-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01832225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist