Provider Demographics
NPI:1194164459
Name:WILDER, LESLIE BRODIE (LCMHCS, LCAS)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:BRODIE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LCMHCS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4804 WEDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3981
Mailing Address - Country:US
Mailing Address - Phone:910-619-0760
Mailing Address - Fax:
Practice Address - Street 1:4804 WEDGEFIELD DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-3981
Practice Address - Country:US
Practice Address - Phone:910-619-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3294101YA0400X
NC10318101YP2500X
NCS10318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional