Provider Demographics
NPI:1013050046
Name:WILDERMUTH, REBECCA ANNE (MS ATC CSCS)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANNE
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:MS ATC CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-862-1786
Mailing Address - Fax:
Practice Address - Street 1:10 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936
Practice Address - Country:US
Practice Address - Phone:217-784-2650
Practice Address - Fax:217-784-8023
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer