Healthcare Provider Details

I. General information

NPI: 1043120926
Provider Name (Legal Business Name): WILDER WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21223 CATAWBA AVE
CORNELIUS NC
28031-8504
US

IV. Provider business mailing address

21223 CATAWBA AVE
CORNELIUS NC
28031-8504
US

V. Phone/Fax

Practice location:
  • Phone: 704-912-4236
  • Fax:
Mailing address:
  • Phone: 704-912-4236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM FRANK WILDER III
Title or Position: OWNER
Credential: LCMHC
Phone: 704-912-4236