Provider Demographics
NPI:1235893371
Name:WILDER, PETER L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:L
Last Name:WILDER
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E IVY ST
Mailing Address - Street 2:
Mailing Address - City:EAST ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14445-1636
Mailing Address - Country:US
Mailing Address - Phone:585-732-2192
Mailing Address - Fax:
Practice Address - Street 1:110 E IVY ST
Practice Address - Street 2:
Practice Address - City:EAST ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14445-1636
Practice Address - Country:US
Practice Address - Phone:585-732-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0810491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical