Provider Demographics
NPI:1205303138
Name:WYDERMYER, CHARDE MARIE
Entity type:Individual
Prefix:
First Name:CHARDE
Middle Name:MARIE
Last Name:WYDERMYER
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 1:2523 WITHROW LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6579
Mailing Address - Country:US
Mailing Address - Phone:510-860-6470
Mailing Address - Fax:
Practice Address - Street 1:180 E LELAND RD STE A&B
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-4949
Practice Address - Country:US
Practice Address - Phone:925-427-9100
Practice Address - Fax:925-427-9102
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)