Healthcare Provider Details

I. General information

NPI: 1447482518
Provider Name (Legal Business Name): FERD WILDER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHIP WILDER MSW

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 EXCHANGE ST
MILLIS MA
02054-1212
US

IV. Provider business mailing address

142 EXCHANGE ST
MILLIS MA
02054-1212
US

V. Phone/Fax

Practice location:
  • Phone: 508-376-6018
  • Fax:
Mailing address:
  • Phone: 508-376-6018
  • Fax: 508-485-8807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102768
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: