Provider Demographics
NPI:1356727879
Name:WILDER, CHARLEEN
Entity type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 W 15TH ST STE 320
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7275
Mailing Address - Country:US
Mailing Address - Phone:704-729-4522
Mailing Address - Fax:
Practice Address - Street 1:14275 MIDWAY RD STE 260
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3613
Practice Address - Country:US
Practice Address - Phone:469-665-9445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist