Healthcare Provider Details

I. General information

NPI: 1629590336
Provider Name (Legal Business Name): LINDSEY WILDEROTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DUMONT PL
MORRISTOWN NJ
07960-8104
US

IV. Provider business mailing address

42 MAGNOLIA DR
NEW PROVIDENCE NJ
07974-1406
US

V. Phone/Fax

Practice location:
  • Phone: 973-998-7900
  • Fax:
Mailing address:
  • Phone: 908-370-4681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00369600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: