Provider Demographics
NPI:1881406478
Name:WILDER, STEPHANIE (MA, LAPC, NCC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:MA, LAPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 BRIAR PATCH LN
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4046
Mailing Address - Country:US
Mailing Address - Phone:770-547-5281
Mailing Address - Fax:
Practice Address - Street 1:650 HENDERSON DR STE 406
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3758
Practice Address - Country:US
Practice Address - Phone:678-842-8502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC010167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health