Provider Demographics
NPI:1093040594
Name:WILDES, CLARE TUCKER
Entity Type:Individual
Prefix:
First Name:CLARE
Middle Name:TUCKER
Last Name:WILDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 N MARINE DR
Mailing Address - Street 2:SUITE 236
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1744
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:773-404-9876
Practice Address - Street 1:4250 N MARINE DR
Practice Address - Street 2:SUITE 236
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1744
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:773-404-9876
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490093591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical