Individual
JOHN A WILDER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
14818 CAPRICORN LN, CHARLOTTE, NC 28277-2927
(704) 517-2138
Mailing address
13575 58TH ST N, SUITE 187, CLEARWATER, FL 33760-3740
(800) 632-6074
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
3005
NC
103TC0700X
Clinical Psychologist
P3005
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6000785
—
NC
01
—
P00316181
RR MEDICARE # - PARADIGM
NC
Enumeration date
10/04/2006
Last updated
02/27/2020
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