Provider Demographics
NPI:1962165571
Name:WILDER, GABRIELLE ELIZABETH
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ELIZABETH
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7639 AL HIGHWAY 157
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35057-6938
Mailing Address - Country:US
Mailing Address - Phone:334-796-9794
Mailing Address - Fax:
Practice Address - Street 1:164 STRICKLIN RD
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35057-3305
Practice Address - Country:US
Practice Address - Phone:256-469-8493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician