Provider Demographics
NPI:1144967498
Name:WILSEY, RICHARD C (LMT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:WILSEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:C
Other - Last Name:WILSEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:640 E BETSY LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4197
Mailing Address - Country:US
Mailing Address - Phone:480-238-6130
Mailing Address - Fax:
Practice Address - Street 1:640 E BETSY LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4197
Practice Address - Country:US
Practice Address - Phone:480-238-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25214225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist