Provider Demographics
NPI:1053915751
Name:WILDER, MARCEY BLAINE (MS)
Entity type:Individual
Prefix:
First Name:MARCEY
Middle Name:BLAINE
Last Name:WILDER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 MORAVIAN AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6523
Mailing Address - Country:US
Mailing Address - Phone:570-620-6645
Mailing Address - Fax:
Practice Address - Street 1:2823 MORAVIAN AVE
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6523
Practice Address - Country:US
Practice Address - Phone:570-620-6645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC017087101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health