Provider Demographics
NPI:1821070046
Name:WILDER, BETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15196
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98511-5196
Mailing Address - Country:US
Mailing Address - Phone:360-493-2006
Mailing Address - Fax:
Practice Address - Street 1:7618 FAIR OAKS RD SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-6421
Practice Address - Country:US
Practice Address - Phone:360-493-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000616225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7681570Medicaid
WA1045795Medicaid