Provider Demographics
NPI:1679058150
Name:KOHL, WYATT
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:KOHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1972 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-3929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1972 CLARK AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3929
Practice Address - Country:US
Practice Address - Phone:330-581-5376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer