Provider Demographics
NPI:1164517819
Name:WILDER, JOHN A (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:WILDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:13575 58TH ST N
Mailing Address - Street 2:SUITE 187
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3740
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:14818 CAPRICORN LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2927
Practice Address - Country:US
Practice Address - Phone:704-517-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP3005103TC0700X
NC3005103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00316181OtherRR MEDICARE # - PARADIGM
NC6000785Medicaid
NCP00316181OtherRR MEDICARE # - PARADIGM