MEDICARE: JAMES TYRONE WILDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	12209	SC
2	1041C0700X	Clinical Social Worker	13946CP	SC

General Provider Information

NPI Number	:	1346751971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES TYRONE WILDER

Provider Business Mailing Address
First Line	:	501 BELLE HALL PKWY UNIT 102
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-8322
Country	:	US
Telephone Number	:	843-225-0567
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 BELLE HALL PKWY UNIT 102
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-8322
Country	:	US
Telephone Number	:	843-225-0567
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2017
Last Update Date	:	07/09/2021

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