Provider Demographics
NPI:1417294133
Name:WILDER, EVELYN IRIS (LPC-MH, QMHP, LAC)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:IRIS
Last Name:WILDER
Suffix:
Gender:F
Credentials:LPC-MH, QMHP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 EVEREST RD
Mailing Address - Street 2:LOT 48
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9638
Mailing Address - Country:US
Mailing Address - Phone:605-348-6086
Mailing Address - Fax:605-348-1050
Practice Address - Street 1:529 KANSAS CITY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3693
Practice Address - Country:US
Practice Address - Phone:605-348-6086
Practice Address - Fax:605-348-1050
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12091537101YA0400X
SDLPC-MH2289101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)