Provider Demographics
NPI:1538362199
Name:WILDER, JUDY DIANA (LPC, LADC)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:DIANA
Last Name:WILDER
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 E 35TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2514
Mailing Address - Country:US
Mailing Address - Phone:918-748-8894
Mailing Address - Fax:
Practice Address - Street 1:7010 S YALE AVE STE 215
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5743
Practice Address - Country:US
Practice Address - Phone:918-492-2554
Practice Address - Fax:918-494-9870
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional