Provider Demographics
NPI:1023346517
Name:WILT, CHADWICK ANSELM (PC)
Entity type:Individual
Prefix:
First Name:CHADWICK
Middle Name:ANSELM
Last Name:WILT
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7413 MAXTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9040
Mailing Address - Country:US
Mailing Address - Phone:614-818-4099
Mailing Address - Fax:
Practice Address - Street 1:7413 MAXTOWN RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9040
Practice Address - Country:US
Practice Address - Phone:614-818-4099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0701196101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional