Provider Demographics
NPI:1467044859
Name:WILDER, THOMAS HENRY (LPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HENRY
Last Name:WILDER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-3020
Mailing Address - Country:US
Mailing Address - Phone:469-240-1580
Mailing Address - Fax:
Practice Address - Street 1:110 JACKSON ST
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-3020
Practice Address - Country:US
Practice Address - Phone:469-240-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77731101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional