Provider Demographics
NPI:1124193545
Name:WILDMAN, CAROL A (LICSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HANOVER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1312
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:603-448-6001
Practice Address - Street 1:52 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-3055
Practice Address - Country:US
Practice Address - Phone:603-542-2578
Practice Address - Fax:603-342-5436
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH16931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE2534Medicare PIN