Provider Demographics
NPI:1174186886
Name:WILDER, TERI MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:MARIE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 DOWLING ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-9436
Mailing Address - Country:US
Mailing Address - Phone:260-347-4400
Mailing Address - Fax:260-347-3122
Practice Address - Street 1:1930 DOWLING ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-9436
Practice Address - Country:US
Practice Address - Phone:260-347-4400
Practice Address - Fax:260-347-3122
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003506A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health