Provider Demographics
NPI:1932658804
Name:WILD, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:WILD
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 1:4161 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-8311
Mailing Address - Country:US
Mailing Address - Phone:585-506-8496
Mailing Address - Fax:
Practice Address - Street 1:700 LIBERTY CMNS
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2064
Practice Address - Country:US
Practice Address - Phone:315-789-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020931-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist