Provider Demographics
NPI:1578180600
Name:WILDER, ARTESIA RENEE
Entity Type:Individual
Prefix:
First Name:ARTESIA
Middle Name:RENEE
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 UNIVERSITY PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6907
Mailing Address - Country:US
Mailing Address - Phone:269-224-2498
Mailing Address - Fax:
Practice Address - Street 1:2111 UNIVERSITY PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6907
Practice Address - Country:US
Practice Address - Phone:269-224-2498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222971101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor