Provider Demographics
NPI:1417680976
Name:WILDER, JOAN (OTR)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 NW FIELDS ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7324
Mailing Address - Country:US
Mailing Address - Phone:541-678-0992
Mailing Address - Fax:
Practice Address - Street 1:1662 NW FIELDS ST UNIT 1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7324
Practice Address - Country:US
Practice Address - Phone:541-678-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR302551225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty