Provider Demographics
NPI:1154682532
Name:WILDER, SHEREE LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHEREE
Middle Name:LYNN
Last Name:WILDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHEREE
Other - Middle Name:LYNN
Other - Last Name:MICHAELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1115 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7501
Mailing Address - Country:US
Mailing Address - Phone:508-580-4691
Mailing Address - Fax:508-580-5162
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:508-580-5162
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-02
Last Update Date:2012-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00010641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical