Provider Demographics
NPI:1750512000
Name:WILDERMUTH, SHERIE J
Entity Type:Individual
Prefix:
First Name:SHERIE
Middle Name:J
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 BOBBY ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-1705
Mailing Address - Country:US
Mailing Address - Phone:407-658-1182
Mailing Address - Fax:
Practice Address - Street 1:5515 BOBBY ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1705
Practice Address - Country:US
Practice Address - Phone:321-947-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2272W101YA0400X
FLMH9379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)