Basic Information
| Provider Information | |||||||||
| NPI: | 1871888982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDBERGER | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1908 FLINT RD SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356016031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563409708 | ||||||||
| FaxNumber: | 2563409624 | ||||||||
| Practice Location | |||||||||
| Address1: | 30941 MILL LN | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SPANISH FORT | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365275456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516252170 | ||||||||
| FaxNumber: | 2516252172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2011 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT3282 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 529917620 | 05 | AL | MEDICAID | 1003819608 | 01 | AL | GROUP NPI | OTHER |