Provider Demographics
NPI:1760423545
Name:WILMOT, MARTHA ANN
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
Last Name:WILMOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CHICKERING DRIVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301
Mailing Address - Country:US
Mailing Address - Phone:802-258-2337
Mailing Address - Fax:802-258-2307
Practice Address - Street 1:36 CHICKERING DRIVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301
Practice Address - Country:US
Practice Address - Phone:802-258-2337
Practice Address - Fax:802-258-2307
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
394918OtherMVP
VT49636OtherBLUE CROSS BLUE SHIELD
VN2705Medicare ID - Type Unspecified