Provider Demographics
NPI:1386866101
Name:WILDER, H BRUCE (MS, BCBA)
Entity Type:Individual
Prefix:MR
First Name:H
Middle Name:BRUCE
Last Name:WILDER
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W SHOAFF RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-9757
Mailing Address - Country:US
Mailing Address - Phone:260-409-4165
Mailing Address - Fax:
Practice Address - Street 1:205 W SHOAFF RD
Practice Address - Street 2:
Practice Address - City:HUNTERTOWN
Practice Address - State:IN
Practice Address - Zip Code:46748-9757
Practice Address - Country:US
Practice Address - Phone:260-409-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-01-0469174400000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist