Provider Demographics
NPI:1396935847
Name:WILDE, SARA LYNN (OTR)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:LYNN
Last Name:WILDE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:SARA
Other - Middle Name:LYNN
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1504 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3100
Mailing Address - Country:US
Mailing Address - Phone:920-563-9357
Mailing Address - Fax:920-568-6545
Practice Address - Street 1:1504 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3100
Practice Address - Country:US
Practice Address - Phone:920-563-9357
Practice Address - Fax:920-568-6545
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4510-026225X00000X
WI225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41046300Medicaid