Provider Demographics
NPI:1346664505
Name:WILDER THERAPY AND WELLNESS, LLC
Entity type:Organization
Organization Name:WILDER THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:401-406-1101
Mailing Address - Street 1:63 SOCKANOSSET CROSS RD
Mailing Address - Street 2:2A-7
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-5557
Mailing Address - Country:US
Mailing Address - Phone:401-406-1101
Mailing Address - Fax:401-712-8659
Practice Address - Street 1:63 SOCKANOSSET CROSS RD
Practice Address - Street 2:2A-7
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-5557
Practice Address - Country:US
Practice Address - Phone:401-406-1101
Practice Address - Fax:401-712-8659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-08
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891125167OtherINDIVIDUAL NPI- JAMI WILDER
1083943310OtherINDIVIDUAL NPI- HEATHER WILDER