Provider Demographics
NPI:1962638015
Name:WILDER, PAMLEA HARRIS
Entity Type:Individual
Prefix:
First Name:PAMLEA
Middle Name:HARRIS
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, NCC
Mailing Address - Street 1:4858 AMSTEL PL
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5749
Mailing Address - Country:US
Mailing Address - Phone:678-617-7448
Mailing Address - Fax:
Practice Address - Street 1:4858 AMSTEL PL
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5749
Practice Address - Country:US
Practice Address - Phone:678-617-7448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004535101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional