Provider Demographics
NPI:1407631955
Name:WILDMAN, BRAYLEE KRISANNA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:BRAYLEE
Middle Name:KRISANNA
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 CHAPMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:ME
Mailing Address - Zip Code:04444-5150
Mailing Address - Country:US
Mailing Address - Phone:207-656-9241
Mailing Address - Fax:
Practice Address - Street 1:12 WESTBROOK CMN
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2819
Practice Address - Country:US
Practice Address - Phone:207-591-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT4533225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist