Provider Demographics
NPI:1548598204
Name:MICHELLE WILDMAN, OCCUPATIONAL THERAPIST, P.A.
Entity Type:Organization
Organization Name:MICHELLE WILDMAN, OCCUPATIONAL THERAPIST, P.A.
Other - Org Name:KIDZ KORNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WILDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:850-543-6227
Mailing Address - Street 1:122 EGLIN PKWY NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4917
Mailing Address - Country:US
Mailing Address - Phone:850-543-6227
Mailing Address - Fax:850-863-9973
Practice Address - Street 1:122 EGLIN PKWY NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4917
Practice Address - Country:US
Practice Address - Phone:850-543-6227
Practice Address - Fax:850-863-9973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11903251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services