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General NPI Number Information
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NPI Number | 1356727879
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Entity Type | Individual
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Provider Name | CHARLEEN WILDER
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Gender | Female
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Dates
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Enumeration Date | 08/06/2015
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 14275 MIDWAY RD STE 260
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City | ADDISON
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State | TX
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Zip | 75001-3613
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Country | US
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Telephone | 469-665-9445
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Fax |
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Provider Business Mailing Address
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Address Line | 1255 W 15TH ST STE 320
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City | PLANO
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State | TX
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Zip | 75075-7275
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Country | US
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Telephone | 704-729-4522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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