Provider Demographics
NPI:1902920085
Name:WILDMAN, TIMOTHY JOAL (DMIN)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOAL
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3048
Mailing Address - Country:US
Mailing Address - Phone:603-225-5606
Mailing Address - Fax:603-225-5604
Practice Address - Street 1:54 AUBURN ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3048
Practice Address - Country:US
Practice Address - Phone:603-225-5606
Practice Address - Fax:603-225-5604
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH18101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral