Provider Demographics
NPI:1821459264
Name:WILDES, DANIELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WILDES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 NEWNAN ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3428
Mailing Address - Country:US
Mailing Address - Phone:678-796-8255
Mailing Address - Fax:
Practice Address - Street 1:605 NEWNAN ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3428
Practice Address - Country:US
Practice Address - Phone:678-796-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-13
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001451106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist