Provider Demographics
NPI:1568155505
Name:WILDER, MITCHELL (OT)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 WILLIAM WILDER RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-8508
Mailing Address - Country:US
Mailing Address - Phone:606-269-7680
Mailing Address - Fax:
Practice Address - Street 1:3450 RICHMOND RD STE 130
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2742
Practice Address - Country:US
Practice Address - Phone:859-224-2273
Practice Address - Fax:859-224-4675
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY281329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist