Provider Demographics
NPI:1912770694
Name:WILDERMUTH, DIANA (PHD, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:PHD, LPC, NCC
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:BAUMEISTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1348 BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-4783
Mailing Address - Country:US
Mailing Address - Phone:610-368-1033
Mailing Address - Fax:
Practice Address - Street 1:1348 BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-4783
Practice Address - Country:US
Practice Address - Phone:610-368-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4484204101YS0200X
PA007204101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool