Provider Demographics
NPI:1760265854
Name:WILCZYNSKI, WALTER TREVOR (DPT)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:TREVOR
Last Name:WILCZYNSKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:226 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-2807
Practice Address - Country:US
Practice Address - Phone:865-657-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TN16176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist