Provider Demographics
NPI:1851911127
Name:WILDER, THEODORE RYKER (LCPC)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RYKER
Last Name:WILDER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:NITSCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1147 BROOK FOREST AVE # 214
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-8845
Mailing Address - Country:US
Mailing Address - Phone:779-707-0597
Mailing Address - Fax:
Practice Address - Street 1:3505 GREENMEADOW LN
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-4807
Practice Address - Country:US
Practice Address - Phone:815-786-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014535101YM0800X
IL180015246101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1134554827OtherPRIVATE INSURANCE