Provider Demographics
NPI:1164199865
Name:WILDER, TORY ELANA (DPT)
Entity Type:Individual
Prefix:
First Name:TORY
Middle Name:ELANA
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 1:90 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9423
Mailing Address - Country:US
Mailing Address - Phone:423-231-1040
Mailing Address - Fax:
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3122
Practice Address - Country:US
Practice Address - Phone:802-857-5976
Practice Address - Fax:802-857-5175
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0134304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist