Provider Demographics
NPI:1821127812
Name:WILDER, ELAINE (PT)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 WAYFARER DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7523
Mailing Address - Country:US
Mailing Address - Phone:314-977-8505
Mailing Address - Fax:314-977-8513
Practice Address - Street 1:3437 CAROLINE ST
Practice Address - Street 2:ROOM 1015
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1111
Practice Address - Country:US
Practice Address - Phone:314-977-8538
Practice Address - Fax:314-977-8513
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist