Provider Demographics
NPI:1821239955
Name:WILDER, MELVYN JR (CASAC)
Entity Type:Individual
Prefix:MR
First Name:MELVYN
Middle Name:
Last Name:WILDER
Suffix:JR
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 JOHN ST FL 27
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-3414
Mailing Address - Country:US
Mailing Address - Phone:212-964-0128
Mailing Address - Fax:212-964-0113
Practice Address - Street 1:116 JOHN ST FL 27
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-3414
Practice Address - Country:US
Practice Address - Phone:212-964-0128
Practice Address - Fax:212-964-0113
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)