Provider Demographics
NPI:1760114243
Name:WILDFREE KIDS OT, LLC
Entity Type:Organization
Organization Name:WILDFREE KIDS OT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MOT, OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:MOT
Authorized Official - Phone:907-215-4438
Mailing Address - Street 1:PO BOX 872579
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-2579
Mailing Address - Country:US
Mailing Address - Phone:907-215-4438
Mailing Address - Fax:907-215-4707
Practice Address - Street 1:4508 S CARILLON DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-0202
Practice Address - Country:US
Practice Address - Phone:907-215-4438
Practice Address - Fax:907-215-4707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-24
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1730280Medicaid