Provider Demographics
NPI:1962639195
Name:WILD, DESIREE (COTA)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 HOME RD
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:WI
Mailing Address - Zip Code:53039-1401
Mailing Address - Country:US
Mailing Address - Phone:920-386-3500
Mailing Address - Fax:920-386-3812
Practice Address - Street 1:199 HOME RD
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-1401
Practice Address - Country:US
Practice Address - Phone:920-386-3500
Practice Address - Fax:920-386-3812
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI335-027171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator