Provider Demographics
NPI:1568655512
Name:WILDER, VIRGINIA CUTHBERT (M ED)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:CUTHBERT
Last Name:WILDER
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LINWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-4327
Mailing Address - Country:US
Mailing Address - Phone:843-871-9697
Mailing Address - Fax:
Practice Address - Street 1:130 LINWOOD LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-4327
Practice Address - Country:US
Practice Address - Phone:843-871-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1330101YP2500X
SC1331106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional