Provider Demographics
NPI:1154976181
Name:WILDER, ANNA (MOTR/L)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 SENDA DEL VALLE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7178
Mailing Address - Country:US
Mailing Address - Phone:505-920-7966
Mailing Address - Fax:
Practice Address - Street 1:1800 OLD PECOS TRL
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4759
Practice Address - Country:US
Practice Address - Phone:505-424-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist