Healthcare Provider Details

I. General information

NPI: 1902920085
Provider Name (Legal Business Name): TIMOTHY JOAL WILDMAN D.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 AUBURN ST
CONCORD NH
03301-3048
US

IV. Provider business mailing address

54 AUBURN ST
CONCORD NH
03301-3048
US

V. Phone/Fax

Practice location:
  • Phone: 603-225-5606
  • Fax: 603-225-5604
Mailing address:
  • Phone: 603-225-5606
  • Fax: 603-225-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number18
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: