Healthcare Provider Details

I. General information

NPI: 1912770694
Provider Name (Legal Business Name): DIANA WILDERMUTH PHD, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANA BAUMEISTER

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 BROWNSVILLE RD
COATESVILLE PA
19320-4783
US

IV. Provider business mailing address

1348 BROWNSVILLE RD
COATESVILLE PA
19320-4783
US

V. Phone/Fax

Practice location:
  • Phone: 610-368-1033
  • Fax:
Mailing address:
  • Phone: 610-368-1033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number007204
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number4484204
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: