Provider Demographics
NPI:1285902528
Name:WILDMAN, DOUGLAS ALAN (MA, PACCC ASSOCIAT)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:MA, PACCC ASSOCIAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 93
Mailing Address - Street 2:
Mailing Address - City:NORQUAY
Mailing Address - State:SK
Mailing Address - Zip Code:S0A 2V0
Mailing Address - Country:CA
Mailing Address - Phone:306-594-2035
Mailing Address - Fax:
Practice Address - Street 1:117 - 2ND STREET EAST
Practice Address - Street 2:
Practice Address - City:NORQUAY
Practice Address - State:SK
Practice Address - Zip Code:S0A 2V0
Practice Address - Country:CA
Practice Address - Phone:306-594-2035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional