Healthcare Provider Details

I. General information

NPI: 1043147119
Provider Name (Legal Business Name): PORCHLIGHT MARRIAGE AND FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CLARK ST STE 1
TUPELO MS
38804-4809
US

IV. Provider business mailing address

PO BOX 132
TUPELO MS
38802-0132
US

V. Phone/Fax

Practice location:
  • Phone: 662-205-0197
  • Fax: 662-346-2821
Mailing address:
  • Phone: 662-205-0197
  • Fax: 662-346-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MARTIN THOMAS WILDEMAN
Title or Position: OWNER
Credential: LMFT
Phone: 662-205-0197