Provider Demographics
NPI:1710999537
Name:WILDER, ROBERT EDWARD JR (MDIV, MED)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EDWARD
Last Name:WILDER
Suffix:JR
Gender:M
Credentials:MDIV, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 LOCHAMY LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5479
Mailing Address - Country:US
Mailing Address - Phone:904-866-1556
Mailing Address - Fax:904-287-7576
Practice Address - Street 1:11924 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1840
Practice Address - Country:US
Practice Address - Phone:904-866-1556
Practice Address - Fax:904-287-7576
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 0001634106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist