Provider Demographics
NPI:1447534177
Name:WILHELM, DESARE R (LMT)
Entity type:Individual
Prefix:MISS
First Name:DESARE
Middle Name:R
Last Name:WILHELM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 CR 424
Mailing Address - Street 2:
Mailing Address - City:ANTWERP
Mailing Address - State:OH
Mailing Address - Zip Code:45813
Mailing Address - Country:US
Mailing Address - Phone:419-789-9602
Mailing Address - Fax:
Practice Address - Street 1:104 E. HIGH ST.
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526
Practice Address - Country:US
Practice Address - Phone:419-789-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.018671225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist