Provider Demographics
NPI:1265507123
Name:RACK WILDNER, GERARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:
Last Name:RACK WILDNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 EAST MCMURRAY ROAD
Mailing Address - Street 2:
Mailing Address - City:MCMURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-2948
Mailing Address - Country:US
Mailing Address - Phone:724-969-4330
Mailing Address - Fax:724-969-4332
Practice Address - Street 1:226 EAST MCMURRAY ROAD
Practice Address - Street 2:
Practice Address - City:MCMURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-2948
Practice Address - Country:US
Practice Address - Phone:724-969-4330
Practice Address - Fax:724-969-4332
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006293L103T00000X
PAMF000236106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA033816Medicare ID - Type Unspecified