Provider Demographics
NPI:1427756089
Name:WILDMAN, JUDITH (MSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SKYLAR RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7348
Mailing Address - Country:US
Mailing Address - Phone:718-902-8132
Mailing Address - Fax:
Practice Address - Street 1:PATHWAYS CENTER SPALDING
Practice Address - Street 2:1710 HIGHWAY 16 WEST
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37782101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)