Provider Demographics
NPI:1881732618
Name:WILDES, NIC (LMHC)
Entity type:Individual
Prefix:
First Name:NIC
Middle Name:
Last Name:WILDES
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:WILDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:PO BOX 1321
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-5321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 SEWALL AVE
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5102
Practice Address - Country:US
Practice Address - Phone:617-203-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6217101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health