Provider Demographics
NPI:1003962317
Name:WILDMAN, MICHELLE ANNE (OTRL)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNE
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 RADFORD CT
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2169
Mailing Address - Country:US
Mailing Address - Phone:850-543-6227
Mailing Address - Fax:850-863-9974
Practice Address - Street 1:122 EGLIN PKWY NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4917
Practice Address - Country:US
Practice Address - Phone:850-543-6227
Practice Address - Fax:850-863-9974
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11903251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services