Provider Demographics
NPI:1720735707
Name:WILDER, THOMAS PERRY
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PERRY
Last Name:WILDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 MOUNTAIN CREST RD
Mailing Address - Street 2:
Mailing Address - City:SWANNANOA
Mailing Address - State:NC
Mailing Address - Zip Code:28778-2314
Mailing Address - Country:US
Mailing Address - Phone:828-899-0007
Mailing Address - Fax:
Practice Address - Street 1:320 MOUNTAIN CREST RD
Practice Address - Street 2:
Practice Address - City:SWANNANOA
Practice Address - State:NC
Practice Address - Zip Code:28778-2314
Practice Address - Country:US
Practice Address - Phone:828-899-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14474103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling