Provider Demographics
NPI:1477862126
Name:WILDMAN, HEATHER DAVON
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAVON
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 E DEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2315
Mailing Address - Country:US
Mailing Address - Phone:617-292-9200
Mailing Address - Fax:
Practice Address - Street 1:72 E DEDHAM ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2315
Practice Address - Country:US
Practice Address - Phone:617-292-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2177241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical