Provider Demographics
NPI:1811312713
Name:WILDER, ALLAN
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:
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 1:19311 BRETTON DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1203
Mailing Address - Country:US
Mailing Address - Phone:313-831-3160
Mailing Address - Fax:313-831-2604
Practice Address - Street 1:19311 BRETTON DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1203
Practice Address - Country:US
Practice Address - Phone:313-831-3160
Practice Address - Fax:313-831-2604
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health