MEDICARE: THOMAS HENRY WILDER LPC

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	101YP2500X	Professional Counselor	77731	TX

General Provider Information

NPI Number	:	1467044859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS HENRY WILDER LPC

Provider Business Mailing Address
First Line	:	110 JACKSON ST
Second Line	:
City	:	WETUMPKA
State	:	AL
Zip	:	36092-3020
Country	:	US
Telephone Number	:	469-240-1580
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 JACKSON ST
Second Line	:
City	:	WETUMPKA
State	:	AL
Zip	:	36092-3020
Country	:	US
Telephone Number	:	469-240-1580
Fax Number	:

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

Provider Enumeration Date	:	02/07/2021
Last Update Date	:	02/07/2021

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Directions to “ THOMAS HENRY WILDER LPC” Practice Location

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