Provider Demographics
NPI:1285105114
Name:WILDER, VANESSA B
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:B
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 1:20 SUTHERLAND DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:27525-6614
Mailing Address - Country:US
Mailing Address - Phone:774-232-2390
Mailing Address - Fax:
Practice Address - Street 1:1756 HERITAGE CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-8796
Practice Address - Country:US
Practice Address - Phone:919-438-2167
Practice Address - Fax:919-728-5279
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14472101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional