Provider Demographics
NPI:1659116101
Name:WILDE, SAMANTHA CAROL (CMT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CAROL
Last Name:WILDE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W 2ND ST APT 413
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-8203
Mailing Address - Country:US
Mailing Address - Phone:562-666-5598
Mailing Address - Fax:
Practice Address - Street 1:301 W 2ND ST APT 413
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-8203
Practice Address - Country:US
Practice Address - Phone:562-666-5598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist