Provider Demographics
NPI:1306567672
Name:WILDMAN, DENNIS (CSW)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W 100 N STE 210
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9826
Mailing Address - Country:US
Mailing Address - Phone:435-755-6061
Mailing Address - Fax:435-994-8362
Practice Address - Street 1:1515 N 400 E STE 104
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7595
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:435-755-6091
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261828-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker