Provider Demographics
NPI:1326091968
Name:WILDERMUTH, MARY W (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 A HIGHWAY 17 BYPASS
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9326
Mailing Address - Country:US
Mailing Address - Phone:843-215-8787
Mailing Address - Fax:843-215-8670
Practice Address - Street 1:9250 A HIGHWAY 17 BYPASS
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9326
Practice Address - Country:US
Practice Address - Phone:843-215-8787
Practice Address - Fax:843-215-8670
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0328Medicaid