Provider Demographics
NPI:1871019034
Name:DEWILDE, ROGER TODD (MED LPC-MHSP(TEMP))
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:TODD
Last Name:DEWILDE
Suffix:
Gender:M
Credentials:MED LPC-MHSP(TEMP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 SUMNER HALL DR
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3129
Mailing Address - Country:US
Mailing Address - Phone:615-460-4500
Mailing Address - Fax:
Practice Address - Street 1:332 SUMNER HALL DR
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-3129
Practice Address - Country:US
Practice Address - Phone:615-460-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-19
Last Update Date:2017-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health