Provider Demographics
NPI:1831287135
Name:WILDMAN, BETH G (PHD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:G
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 GRAHAM ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223
Mailing Address - Country:US
Mailing Address - Phone:930-929-1326
Mailing Address - Fax:330-929-1327
Practice Address - Street 1:96 GRAHAM ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223
Practice Address - Country:US
Practice Address - Phone:330-929-1326
Practice Address - Fax:330-929-1327
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3224103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0819967Medicaid
OHWICP18901Medicare ID - Type Unspecified