Provider Demographics
NPI:1356427181
Name:WILDE, ROGER KENNETH (EDD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:KENNETH
Last Name:WILDE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5704 THUNDER RD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33876-5400
Mailing Address - Country:US
Mailing Address - Phone:863-414-3970
Mailing Address - Fax:954-366-2056
Practice Address - Street 1:5704 THUNDER RD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33876-5400
Practice Address - Country:US
Practice Address - Phone:863-414-3970
Practice Address - Fax:863-655-4978
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75100Medicare UPIN