Provider Demographics
NPI:1689249435
Name:WILDS, MONICA JEAN (MSOT)
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:JEAN
Last Name:WILDS
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:JEAN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:897 MILL ST
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-2150
Mailing Address - Country:US
Mailing Address - Phone:989-331-4068
Mailing Address - Fax:
Practice Address - Street 1:615 S BOWER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2628
Practice Address - Country:US
Practice Address - Phone:616-754-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010806225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist