Provider Demographics
NPI:1073919155
Name:WILDER, KIMBERLY DIANE (LMHC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIANE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DIANE
Other - Last Name:SANDERS(CHRISTIAN)
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WILDER WELLNESS, LLC
Mailing Address - Street 1:1114 THOMASVILLE RD STE W
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-6273
Mailing Address - Country:US
Mailing Address - Phone:850-273-0199
Mailing Address - Fax:850-792-2491
Practice Address - Street 1:1114 THOMASVILLE RD STE W
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6273
Practice Address - Country:US
Practice Address - Phone:850-273-0199
Practice Address - Fax:850-792-2491
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13838101YM0800X
FLMH14823101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health