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NPI Code Detail

MEDICARE: WILDER PSYCHOLOGY, PLLC

MEDICARE: WILDER PSYCHOLOGY, PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor
2103T00000XPsychologist

General Provider Information

NPI Number : 1184413999
Entity Type Code : Organization
Provider Name (Legal Business Name) : WILDER PSYCHOLOGY, PLLC
Provider Business Mailing Address
First Line : 1255 W 15TH ST STE 320
Second Line :
City : PLANO
State : TX
Zip : 75075-7275
Country : US
Telephone Number : 972-519-1692
Fax Number :
Provider Business Practice Location Address
First Line : 1255 W 15TH ST STE 320
Second Line :
City : PLANO
State : TX
Zip : 75075-7275
Country : US
Telephone Number : 972-519-1692
Fax Number :
Authorized Official
Title or Position : CLINICAL DIRECTOR
Name : CHARLEEN WILDER
Credential : PSYD
Telephone Number : 972-519-1692
Provider Enumeration Date : 05/06/2025
Last Update Date : 05/06/2025

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