Healthcare Provider Details

I. General information

NPI: 1124491790
Provider Name (Legal Business Name): JULIE WILDER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 S MADISON DR
TEMPE AZ
85281-7248
US

IV. Provider business mailing address

618 S MADISON DR
TEMPE AZ
85281-7248
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-1514
  • Fax:
Mailing address:
  • Phone: 480-784-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC15822
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: