Provider Demographics
NPI:1326476565
Name:WILDER, KASEJA LAURINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KASEJA
Middle Name:LAURINE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:LAURINE
Other - Last Name:NEBERGALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1292 HIGH ST #160
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-844-5038
Mailing Address - Fax:
Practice Address - Street 1:575 KINGSWOOD AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405
Practice Address - Country:US
Practice Address - Phone:541-844-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2019-05-22
Deactivation Date:2019-01-12
Deactivation Code:
Reactivation Date:2019-05-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019047Medicaid