Provider Demographics
NPI:1417295056
Name:WILDER, MELISSA LORIEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LORIEN
Last Name:WILDER
Suffix:
Gender:F
Credentials:LCSW
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 13013
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-0013
Mailing Address - Country:US
Mailing Address - Phone:804-426-3728
Mailing Address - Fax:
Practice Address - Street 1:9844 LORI RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6691
Practice Address - Country:US
Practice Address - Phone:804-706-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040075641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical