Provider Demographics
NPI:1366981342
Name:WILD, SANDRA (OTR/L)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:EASTLEY
Other - Last Name:WILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:419 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1536
Mailing Address - Country:US
Mailing Address - Phone:814-931-0543
Mailing Address - Fax:
Practice Address - Street 1:163 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1245
Practice Address - Country:US
Practice Address - Phone:717-248-3941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004566L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist