Provider Demographics
NPI:1215454897
Name:WILDER, REBECCA J (DROT, LOTR)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:WILDER
Suffix:
Gender:F
Credentials:DROT, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4204
Mailing Address - Country:US
Mailing Address - Phone:318-813-2970
Mailing Address - Fax:318-813-2981
Practice Address - Street 1:1450 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-813-2970
Practice Address - Fax:318-813-2981
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16401225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist