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General NPI Number Information
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NPI Number | 1043147119
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Entity Type | Organization
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Legal Business Name | PORCHLIGHT MARRIAGE AND FAMILY THERAPY
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Dates
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Enumeration Date | 05/05/2026
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Last Update Date | 05/05/2026
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Provider Practice Location Address
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Address Line | 113 CLARK ST STE 1
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City | TUPELO
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State | MS
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Zip | 38804-4809
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Country | US
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Telephone | 662-205-0197
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Fax | 662-346-2821
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Provider Business Mailing Address
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Address Line | PO BOX 132
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City | TUPELO
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State | MS
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Zip | 38802-0132
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Country | US
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Telephone | 662-205-0197
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Fax | 662-346-2821
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Authorized Official
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Title or Position | OWNER
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Name | MARTIN THOMAS WILDEMAN
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Credential | LMFT
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Telephone | 662-205-0197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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