Provider Demographics
NPI:1437692654
Name:WILDER, LAQUITTA ANTIONETTE (LMSW)
Entity Type:Individual
Prefix:
First Name:LAQUITTA
Middle Name:ANTIONETTE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 S GRAND BLVD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1034
Mailing Address - Country:US
Mailing Address - Phone:314-577-0444
Mailing Address - Fax:
Practice Address - Street 1:3115 S GRAND BLVD
Practice Address - Street 2:SUITE 450
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1034
Practice Address - Country:US
Practice Address - Phone:314-577-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016040915104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker