Provider Demographics
NPI:1952559197
Name:WILDE, RICHARD LEE (COTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:WILDE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 SIMS DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-7711
Mailing Address - Country:US
Mailing Address - Phone:469-272-0887
Mailing Address - Fax:817-202-0017
Practice Address - Street 1:1108 W KILPATRICK ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7477
Practice Address - Country:US
Practice Address - Phone:817-202-9520
Practice Address - Fax:817-202-0017
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208464224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant