Basic Information
| Provider Information | |||||||||
| NPI: | 1235331075 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAWN MARIE WILDERMUTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUNCOAST THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 411 COMMERCIAL CT | ||||||||
| Address2: | STE F | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342921650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414686701 | ||||||||
| FaxNumber: | 9414850519 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 COMMERCIAL CT | ||||||||
| Address2: | STE F | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342921650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414686701 | ||||||||
| FaxNumber: | 9414850519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 07/04/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILDERMUTH | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9414686701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS CCC/SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 886436500 | 05 | FL | MEDICAID | S1872 | 01 | FL | BC/BS | OTHER |