Basic Information
| Provider Information | |||||||||
| NPI: | 1407436918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDHABER | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENGES | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2303 HIGGINS RD STE A | ||||||||
| Address2: | |||||||||
| City: | PLATTE CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640799232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168580252 | ||||||||
| FaxNumber: | 8165850253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-06762 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2021028503 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.