Provider Demographics
NPI:1003661398
Name:WILD, TORRY
Entity type:Individual
Prefix:
First Name:TORRY
Middle Name:
Last Name:WILD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:432 E SPRING ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1153
Practice Address - Country:US
Practice Address - Phone:231-722-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
MI7501014226225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174H00000XOther Service ProvidersHealth Educator