Provider Demographics
NPI:1235331075
Name:DAWN MARIE WILDERMUTH
Entity Type:Organization
Organization Name:DAWN MARIE WILDERMUTH
Other - Org Name:SUNCOAST THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDERMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:941-468-6701
Mailing Address - Street 1:411 COMMERCIAL CT
Mailing Address - Street 2:STE F
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-1650
Mailing Address - Country:US
Mailing Address - Phone:941-468-6701
Mailing Address - Fax:941-485-0519
Practice Address - Street 1:411 COMMERCIAL CT
Practice Address - Street 2:STE F
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1650
Practice Address - Country:US
Practice Address - Phone:941-468-6701
Practice Address - Fax:941-485-0519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886436500Medicaid
FLS1872OtherBC/BS