Provider Demographics
NPI:1164835849
Name:WILDER, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 S PARK DR STE F
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8945
Mailing Address - Country:US
Mailing Address - Phone:252-327-9415
Mailing Address - Fax:
Practice Address - Street 1:2040 S PARK DR STE F
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8945
Practice Address - Country:US
Practice Address - Phone:252-751-0865
Practice Address - Fax:616-619-6015
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3069-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)