Provider Demographics
NPI:1003366238
Name:LORI WILDER LLC
Entity Type:Organization
Organization Name:LORI WILDER LLC
Other - Org Name:WILDER COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:616-402-4262
Mailing Address - Street 1:41 WASHINGTON AVE STE 384
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-3311
Mailing Address - Country:US
Mailing Address - Phone:616-402-4262
Mailing Address - Fax:616-984-4603
Practice Address - Street 1:41 WASHINGTON AVE STE 384
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-3311
Practice Address - Country:US
Practice Address - Phone:616-402-4262
Practice Address - Fax:616-984-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty