Provider Demographics
NPI:1295878031
Name:WILDER, BEEM (PHD)
Entity type:Individual
Prefix:
First Name:BEEM
Middle Name:
Last Name:WILDER
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 1:19000 HOMESTEAD RD
Mailing Address - Street 2:CHILD PSYCHIATRY
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-0712
Mailing Address - Country:US
Mailing Address - Phone:408-366-4453
Mailing Address - Fax:
Practice Address - Street 1:19000 HOMESTEAD RD
Practice Address - Street 2:CHILD PSYCHIATRY
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0712
Practice Address - Country:US
Practice Address - Phone:408-366-4453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15097103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent