Healthcare Provider Details

I. General information

NPI: 1154976181
Provider Name (Legal Business Name): ANNA WILDER MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 OLD PECOS TRL
SANTA FE NM
87505-4759
US

IV. Provider business mailing address

1262 SENDA DEL VALLE
SANTA FE NM
87507-7178
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-8777
  • Fax:
Mailing address:
  • Phone: 505-920-7966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4130
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: