Provider Demographics
NPI:1063603652
Name:WILDER, ELEANOR KAY (LMFT)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:KAY
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3005
Mailing Address - Country:US
Mailing Address - Phone:831-425-1531
Mailing Address - Fax:
Practice Address - Street 1:555 SOQUEL AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2336
Practice Address - Country:US
Practice Address - Phone:831-425-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC47911102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
N2643674OtherCA DRIVERS LICENSE