Provider Demographics
NPI:1043772494
Name:WILM, MELISSA JEAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:WILM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 MANHATTAN BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-7909
Mailing Address - Country:US
Mailing Address - Phone:812-453-8125
Mailing Address - Fax:812-897-7361
Practice Address - Street 1:3408 MANHATTAN BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-7909
Practice Address - Country:US
Practice Address - Phone:812-453-8125
Practice Address - Fax:812-897-7361
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000266A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist