=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639545973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL RENE WILDER LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2015
-----------------------------------------------------
Last Update Date | 09/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3809 22ND ST 2D
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79410-1198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-789-5146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5731 68TH ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-789-5146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 70258
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------