Provider Demographics
NPI:1962932939
Name:WILD, STEPHANIE (OTR/L)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 64TH AVENUE
Mailing Address - Street 2:#502W
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8254 118TH AVENUE NORTH
Practice Address - Street 2:SUITE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:727-546-8527
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
OT18557225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist