Provider Demographics
NPI:1063613149
Name:WILDER, MARY FRANCES
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:FRANCES
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 OLD COVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7697
Mailing Address - Country:US
Mailing Address - Phone:770-484-1704
Mailing Address - Fax:770-784-3187
Practice Address - Street 1:6612 OLD COVINGTON RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7697
Practice Address - Country:US
Practice Address - Phone:770-484-1704
Practice Address - Fax:770-784-3187
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health