Healthcare Provider Details

I. General information

NPI: 1548821721
Provider Name (Legal Business Name): TINA WILDER MS, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRISTINA URENA MS, BCBA, LBA

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 OFFICE PKWY
EAST PROVIDENCE RI
02914-1643
US

IV. Provider business mailing address

22 10TH ST APT 2
PROVIDENCE RI
02906-2918
US

V. Phone/Fax

Practice location:
  • Phone: 401-270-7110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-63182
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA00435
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: