Provider Demographics
NPI:1619043023
Name:WILDER, CATHERINE CECILIA (LCSW)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:CECILIA
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 1:41 VIDONI DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-1736
Mailing Address - Country:US
Mailing Address - Phone:631-473-6386
Mailing Address - Fax:631-854-2580
Practice Address - Street 1:15 HORSEBLOCK PL
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1204
Practice Address - Country:US
Practice Address - Phone:631-854-2571
Practice Address - Fax:631-854-2580
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043731-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043731-1OtherLICENSE NUMBER
NY5613055OtherCERTIFICATE NUMBER
NY00354807Medicaid
NY5613055OtherCERTIFICATE NUMBER