Provider Demographics
NPI:1386826717
Name:VANDERWILDE, WANDA RAE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:RAE
Last Name:VANDERWILDE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 MONTELLO AVE
Mailing Address - Street 2:A
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1574
Mailing Address - Country:US
Mailing Address - Phone:541-387-3609
Mailing Address - Fax:
Practice Address - Street 1:1115 MONTELLO AVE
Practice Address - Street 2:A
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1574
Practice Address - Country:US
Practice Address - Phone:541-386-2688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist