Provider Demographics
NPI:1114668787
Name:WILDER, KALEIGH (RBT)
Entity Type:Individual
Prefix:
First Name:KALEIGH
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 90TH AVE LOT 203
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-7564
Mailing Address - Country:US
Mailing Address - Phone:772-453-5099
Mailing Address - Fax:
Practice Address - Street 1:1515 INDIAN RIVER BLVD STE A210
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7107
Practice Address - Country:US
Practice Address - Phone:772-774-8224
Practice Address - Fax:772-774-8275
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-199669106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician