Provider Demographics
NPI:1114582483
Name:WILDER, REBECCA (DPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 POLIFKA DR
Mailing Address - Street 2:
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152-5100
Mailing Address - Country:US
Mailing Address - Phone:803-895-8658
Mailing Address - Fax:
Practice Address - Street 1:420 POLIFKA DR
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5100
Practice Address - Country:US
Practice Address - Phone:803-895-8658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.023548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist