Provider Demographics
NPI:1073230686
Name:WILDE, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:FOUGERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813-0605
Mailing Address - Country:US
Mailing Address - Phone:603-413-1070
Mailing Address - Fax:
Practice Address - Street 1:170 KEARSARGE RD
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5331
Practice Address - Country:US
Practice Address - Phone:603-356-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician