Provider Demographics
NPI:1093751455
Name:WILDT, MELISSA GOTTHEIM (OT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:GOTTHEIM
Last Name:WILDT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:RACHEL
Other - Last Name:GOTTHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-991-2034
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:2147 DAVIE AVE
Practice Address - Street 2:GARDENS OF STATESVILLE
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9200
Practice Address - Country:US
Practice Address - Phone:704-878-8689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO221671562Medicare PIN