Provider Demographics
NPI:1609439827
Name:WILDER, CARISA (LCSW)
Entity Type:Individual
Prefix:
First Name:CARISA
Middle Name:
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 1:1444 JEWETT ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6208
Mailing Address - Country:US
Mailing Address - Phone:734-904-9621
Mailing Address - Fax:
Practice Address - Street 1:2020 HOGBACK RD STE 11
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9752
Practice Address - Country:US
Practice Address - Phone:734-904-9621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010867071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical