Provider Demographics
NPI:1588033849
Name:WILDER, CHRISTOPHER ROBIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ROBIN
Last Name:WILDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 848476
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8476
Mailing Address - Country:US
Mailing Address - Phone:254-202-4655
Mailing Address - Fax:254-202-4697
Practice Address - Street 1:2304 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-2467
Practice Address - Country:US
Practice Address - Phone:254-202-7300
Practice Address - Fax:254-202-7350
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10850101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1588033849OtherNPPES