Provider Demographics
NPI:1992076194
Name:WILBUR, TERRY
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:WILBUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3596 TANGERINE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33956-2536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3596 TANGERINE DR
Practice Address - Street 2:
Practice Address - City:SAINT JAMES CITY
Practice Address - State:FL
Practice Address - Zip Code:33956-2536
Practice Address - Country:US
Practice Address - Phone:239-283-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA287224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant