Provider Demographics
NPI:1649978453
Name:WILD, DANIELLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2104
Mailing Address - Country:US
Mailing Address - Phone:732-710-7793
Mailing Address - Fax:
Practice Address - Street 1:1709 LEGION RD STE 100
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-2373
Practice Address - Country:US
Practice Address - Phone:919-932-7266
Practice Address - Fax:919-932-7250
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BCBSOther20Y6E
8347517OtherAETNA