Provider Demographics
NPI:1346416096
Name:WILDER, ANGELLUN VANESSA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANGELLUN
Middle Name:VANESSA
Last Name:WILDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:VANESSA
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4443 PINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-8505
Mailing Address - Country:US
Mailing Address - Phone:318-631-3792
Mailing Address - Fax:
Practice Address - Street 1:3004 KNIGHT ST BLDG 6
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2502
Practice Address - Country:US
Practice Address - Phone:318-603-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA21761041C0700X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171000000XOther Service ProvidersMilitary Health Care Provider