Provider Demographics
NPI:1134873110
Name:WILDER, TABITHA J (LMT)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:J
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 E MAIN ST APT 310
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4072
Mailing Address - Country:US
Mailing Address - Phone:503-713-8768
Mailing Address - Fax:971-251-2306
Practice Address - Street 1:446 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4187
Practice Address - Country:US
Practice Address - Phone:503-713-8768
Practice Address - Fax:971-251-2306
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLMT-26046OtherSTATE OF OREGON LICENSE