Provider Demographics
NPI:1871862086
Name:WILDEMAN, SAMANTHA MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MARIE
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SOUTH AVE W
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8000
Mailing Address - Country:US
Mailing Address - Phone:406-396-5326
Mailing Address - Fax:406-549-1494
Practice Address - Street 1:700 SOUTH AVE W
Practice Address - Street 2:SUITE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8000
Practice Address - Country:US
Practice Address - Phone:406-396-5326
Practice Address - Fax:406-549-1494
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical