Provider Demographics
NPI:1194769802
Name:WILDMAN, HAL E (PHD)
Entity type:Individual
Prefix:
First Name:HAL
Middle Name:E
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 BETA DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2363
Mailing Address - Country:US
Mailing Address - Phone:440-446-9696
Mailing Address - Fax:440-449-1435
Practice Address - Street 1:6700 BETA DR
Practice Address - Street 2:SUITE 301
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44143-2363
Practice Address - Country:US
Practice Address - Phone:440-446-9696
Practice Address - Fax:440-449-1435
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3846103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0690748Medicaid
OHS28796Medicare UPIN