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General NPI Number Information
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NPI Number | 1407041502
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Entity Type | Organization
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Legal Business Name | WILDWOOD PROGRAMS, INC.
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 1190 TROY SCHENECTADY RD
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City | LATHAM
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State | NY
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Zip | 12110-1026
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Country | US
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Telephone | 518-783-3421
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Fax | 518-785-9670
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Provider Business Mailing Address
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Address Line | 2995B CURRY ROAD EXTENSION
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City | SCHENECTADY
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State | NY
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Zip | 12303
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Country | US
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Telephone | 518-356-6410
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Fax | 518-356-3603
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. GARY R. MILFORD
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Credential |
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Telephone | 518-356-6410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 013600
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License Number State | NY
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