Provider Demographics
NPI:1366478323
Name:WILDER, DAVID (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 842
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-0842
Mailing Address - Country:US
Mailing Address - Phone:360-341-3562
Mailing Address - Fax:360-221-2515
Practice Address - Street 1:919 3RD ST STE 101
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9229
Practice Address - Country:US
Practice Address - Phone:360-341-3562
Practice Address - Fax:360-221-2515
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000050301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8139370Medicaid