Provider Demographics
NPI:1942853635
Name:WILDWORKS THERAPY, PLLC
Entity Type:Organization
Organization Name:WILDWORKS THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ST GERMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:207-352-4000
Mailing Address - Street 1:22 PARKWAY S
Mailing Address - Street 2:PO BOX 3461
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412
Mailing Address - Country:US
Mailing Address - Phone:207-352-4000
Mailing Address - Fax:207-808-7259
Practice Address - Street 1:123 MT HOPE AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-352-4000
Practice Address - Fax:207-808-7259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty