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NPI Code Detail

MEDICARE: MR. TIMOTHY M WILDER LPC

MEDICARE: MR. TIMOTHY M WILDER LPC
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
1101YP2500XProfessional Counselor0701002845VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1253575OTHERVAANTHEM BCBS
2272041OTHERVAMAMSI
3272041OTHERVAALLIANCE
4465418OTHERVAVALUE OPTIONS
5199752OTHERVAMANAGED HEALTH NETWORK
67335124OTHERVAAETNA
72041553OTHERVACIGNA

General Provider Information

NPI Number : 1568446144
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TIMOTHY M WILDER LPC
Provider Business Mailing Address
First Line : 4656 BRAMBLETON AVE
Second Line :
City : ROANOKE
State : VA
Zip : 24018-3437
Country : US
Telephone Number : 540-772-8043
Fax Number : 540-772-8242
Provider Business Practice Location Address
First Line : 4656 BRAMBLETON AVE
Second Line :
City : ROANOKE
State : VA
Zip : 24018-3437
Country : US
Telephone Number : 540-772-8043
Fax Number : 540-772-8242
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2005
Last Update Date : 07/09/2007

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Directions to “ MR. TIMOTHY M WILDER LPC” Practice Location

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