Provider Demographics
NPI:1003405747
Name:WILFORD, LEE AUSTIN
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:AUSTIN
Last Name:WILFORD
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 1:2407 N RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-7294
Mailing Address - Country:US
Mailing Address - Phone:989-750-8511
Mailing Address - Fax:
Practice Address - Street 1:500 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-7206
Practice Address - Country:US
Practice Address - Phone:989-750-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-17
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011111225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist