Provider Demographics
NPI:1073547121
Name:WILDER, MARY JOLENE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOLENE
Last Name:WILDER
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 1:265 W CLARK ST
Mailing Address - Street 2:PO BOX 215
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-9604
Mailing Address - Country:US
Mailing Address - Phone:435-224-2726
Mailing Address - Fax:
Practice Address - Street 1:4250 W 5415 S
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-4321
Practice Address - Country:US
Practice Address - Phone:801-969-4181
Practice Address - Fax:801-969-1291
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1388463507101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health