Healthcare Provider Details

I. General information

NPI: 1245999291
Provider Name (Legal Business Name): ATHENA MARIE WILDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

IV. Provider business mailing address

22569 CLIMBING ROSE DR
MORENO VALLEY CA
92557-6033
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 951-254-0696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19703
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: