Basic Information
| Provider Information | |||||||||
| NPI: | 1063613149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6612 OLD COVINGTON RD | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300587697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704841704 | ||||||||
| FaxNumber: | 7707843187 | ||||||||
| Practice Location | |||||||||
| Address1: | 6612 OLD COVINGTON RD | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300587697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704841704 | ||||||||
| FaxNumber: | 7707843187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.