Basic Information
| Provider Information | |||||||||
| NPI: | 1205481298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISLEY | ||||||||
| FirstName: | MADISON | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232388930 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4626 HIGHWAY 58 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374163013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235537972 | ||||||||
| FaxNumber: | 4235537973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2019 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2480 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.