Provider Demographics
NPI:1902298250
Name:WILDBLOOD, ROBERTA ANN (PSYD, MS, RN)
Entity type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:ANN
Last Name:WILDBLOOD
Suffix:
Gender:F
Credentials:PSYD, MS, RN
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Other - First Name:
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Mailing Address - Street 1:1400 N SEMORAN BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-3536
Mailing Address - Country:US
Mailing Address - Phone:407-823-8421
Mailing Address - Fax:407-823-8195
Practice Address - Street 1:1400 N SEMORAN BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3536
Practice Address - Country:US
Practice Address - Phone:407-823-8421
Practice Address - Fax:407-823-8195
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPY8711103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical