Provider Demographics
NPI:1275055907
Name:WILDMAN, DEANNA ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:ELIZABETH
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 S OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2829
Mailing Address - Country:US
Mailing Address - Phone:417-718-1085
Mailing Address - Fax:
Practice Address - Street 1:1302 W SUNSET ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5943
Practice Address - Country:US
Practice Address - Phone:417-718-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017005627224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant