MEDICARE: MICHELLE ANNE WILDMAN OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	11903	FL

General Provider Information

NPI Number	:	1003962317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ANNE WILDMAN OTRL

Provider Business Mailing Address
First Line	:	852 RADFORD CT
Second Line	:
City	:	SHALIMAR
State	:	FL
Zip	:	32579-2169
Country	:	US
Telephone Number	:	850-543-6227
Fax Number	:	850-863-9974

Provider Business Practice Location Address
First Line	:	122 EGLIN PKWY NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4917
Country	:	US
Telephone Number	:	850-543-6227
Fax Number	:	850-863-9974

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2007
Last Update Date	:	07/08/2007

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