Provider Demographics
NPI:1871132886
Name:WILDE, DAPHNE DUFRENE (MS, NCC, LPC)
Entity type:Individual
Prefix:
First Name:DAPHNE
Middle Name:DUFRENE
Last Name:WILDE
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1245
Mailing Address - Country:US
Mailing Address - Phone:334-712-2720
Mailing Address - Fax:334-712-2727
Practice Address - Street 1:134 KATHERINE AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1973
Practice Address - Country:US
Practice Address - Phone:334-803-8667
Practice Address - Fax:334-803-8666
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4189101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor