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General NPI Number Information
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NPI Number | 1568155505
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Entity Type | Individual
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Provider Name | MITCHELL WILDER OT
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Gender | Male
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Dates
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Enumeration Date | 05/26/2023
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Last Update Date | 06/06/2023
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Provider Practice Location Address
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Address Line | 3450 RICHMOND RD STE 130
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City | LEXINGTON
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State | KY
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Zip | 40509-2742
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Country | US
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Telephone | 859-224-2273
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Fax | 859-224-4675
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Provider Business Mailing Address
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Address Line | 193 WILLIAM WILDER RD
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City | PINEVILLE
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State | KY
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Zip | 40977-8508
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Country | US
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Telephone | 606-269-7680
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 281329
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License Number State | KY
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