Provider Demographics
NPI:1194038893
Name:WILDE, DARCE DANAE (PTA)
Entity Type:Individual
Prefix:
First Name:DARCE
Middle Name:DANAE
Last Name:WILDE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DARCE
Other - Middle Name:DANAE
Other - Last Name:COURTNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 S COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-5304
Mailing Address - Country:US
Mailing Address - Phone:405-422-1291
Mailing Address - Fax:405-422-1294
Practice Address - Street 1:1300 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-5304
Practice Address - Country:US
Practice Address - Phone:405-422-1291
Practice Address - Fax:405-422-1294
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1888225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant