Provider Demographics
NPI:1194059709
Name:WILDE, LYNN (COTA)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13150 FM 529 RD STE 114
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-2303
Mailing Address - Country:US
Mailing Address - Phone:713-896-1815
Mailing Address - Fax:
Practice Address - Street 1:13150 FM 529 RD STE 114
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77041-2303
Practice Address - Country:US
Practice Address - Phone:713-896-1815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210021224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant