Provider Demographics
NPI:1699844993
Name:WILDMAN, ANN MARIE (CTRS)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-367-2674
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-385-3232
Practice Address - Fax:208-489-4052
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCTRS43873225800000X
NCTRS43873225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist