Provider Demographics
NPI:1447657069
Name:WILDERMUTH, WANDA (PTA)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13701 STRONG RD
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45340-9704
Mailing Address - Country:US
Mailing Address - Phone:937-726-0413
Mailing Address - Fax:
Practice Address - Street 1:13701 STRONG RD
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45340-9704
Practice Address - Country:US
Practice Address - Phone:937-726-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 1378225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant