Provider Demographics
NPI:1568895738
Name:WILDES, NICOLE SHANNON (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHANNON
Last Name:WILDES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17315-5420
Mailing Address - Country:US
Mailing Address - Phone:717-887-5898
Mailing Address - Fax:717-840-1912
Practice Address - Street 1:50 MOUNT ZION RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-2635
Practice Address - Country:US
Practice Address - Phone:717-887-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007057101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional