Provider Demographics
NPI:1922654912
Name:WILDMON, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WILDMON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 ROAD 1279
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9653
Mailing Address - Country:US
Mailing Address - Phone:662-523-2527
Mailing Address - Fax:
Practice Address - Street 1:447 ROAD 1279
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9653
Practice Address - Country:US
Practice Address - Phone:662-523-2527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS190077103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst