Provider Demographics
NPI:1083890123
Name:WILDERMANN, SUSAN (MA, PD(MFT), LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WILDERMANN
Suffix:
Gender:F
Credentials:MA, PD(MFT), LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07718-1217
Mailing Address - Country:US
Mailing Address - Phone:732-895-7009
Mailing Address - Fax:732-787-3268
Practice Address - Street 1:512 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BELFORD
Practice Address - State:NJ
Practice Address - Zip Code:07718-1217
Practice Address - Country:US
Practice Address - Phone:732-895-7009
Practice Address - Fax:732-787-3268
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-19
Last Update Date:2008-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00357000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional