Active NPI
Mark Wildmon, PH.D.
- Behavior Analyst
- Tupelo, MS
National Provider Identifier
1922654912
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Analyst
- License
- 190077
- Practice address
- 447 Road 1279
Tupelo, MS 38804-9653 - Phone
- (662) 523-2527
- NPI assigned
- Aug 14, 2019
- Last updated
- Aug 14, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Behavior Analyst | 103K00000X | 190077 | MS | Primary |
Addresses
Primary practice location
447 Road 1279
Tupelo, MS 38804-9653
Mailing address
447 Road 1279
Tupelo, MS 38804-9653
Phone (662) 523-2527
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 190077 | MS | MD | Behavioral Analyst |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1565740800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1565740800000",
"number": "1922654912",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "447 ROAD 1279",
"city": "TUPELO",
"state": "MS",
"postal_code": "388049653",
"telephone_number": "662-523-2527"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "447 ROAD 1279",
"city": "TUPELO",
"state": "MS",
"postal_code": "388049653",
"telephone_number": "662-523-2527"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILDMON",
"first_name": "MARK",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2019-08-14",
"last_updated": "2019-08-14",
"status": "A"
},
"taxonomies": [
{
"code": "103K00000X",
"taxonomy_group": "",
"desc": "Behavior Analyst",
"state": "MS",
"license": "190077",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tupelo, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.