Provider Demographics
NPI:1255124202
Name:WILDER, BAARACA (LGPC)
Entity type:Individual
Prefix:
First Name:BAARACA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8473 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1835
Mailing Address - Country:US
Mailing Address - Phone:301-980-0970
Mailing Address - Fax:301-980-0970
Practice Address - Street 1:1900 N HOWARD ST STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5909
Practice Address - Country:US
Practice Address - Phone:443-438-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP16349101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health