Provider Demographics
NPI:1316996473
Name:WILDER, SAMANTHA SUE (OTR)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SUE
Last Name:WILDER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 HAYDEN PIKE
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1411
Mailing Address - Country:US
Mailing Address - Phone:812-346-7508
Mailing Address - Fax:812-346-9040
Practice Address - Street 1:495 HAYDEN PIKE
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1411
Practice Address - Country:US
Practice Address - Phone:812-346-7508
Practice Address - Fax:812-346-9040
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002367A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist