Provider Demographics
NPI:1013010602
Name:WILDEMAN, ISABEL ACOSTA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ISABEL
Middle Name:ACOSTA
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH VILLAGE AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3712
Mailing Address - Country:US
Mailing Address - Phone:516-485-4003
Mailing Address - Fax:516-485-4003
Practice Address - Street 1:100 NORTH VILLAGE AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3712
Practice Address - Country:US
Practice Address - Phone:516-485-4003
Practice Address - Fax:516-485-4003
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR01386211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N02471Medicare ID - Type Unspecified