Provider Demographics
NPI:1700051216
Name:WILDER, AMY CHRISTINE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:CHRISTINE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3314
Mailing Address - Country:US
Mailing Address - Phone:386-944-4707
Mailing Address - Fax:
Practice Address - Street 1:160 N BEACH ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3314
Practice Address - Country:US
Practice Address - Phone:386-944-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 7546101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health