Provider Demographics
NPI:1568446144
Name:WILDER, TIMOTHY M (LPC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
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 1:4656 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3437
Mailing Address - Country:US
Mailing Address - Phone:540-772-8043
Mailing Address - Fax:540-772-8242
Practice Address - Street 1:4656 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3437
Practice Address - Country:US
Practice Address - Phone:540-772-8043
Practice Address - Fax:540-772-8242
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002845101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA253575OtherANTHEM BCBS
VA272041OtherMAMSI
VA272041OtherALLIANCE
VA465418OtherVALUE OPTIONS
VA199752OtherMANAGED HEALTH NETWORK
VA7335124OtherAETNA
VA2041553OtherCIGNA