Provider Demographics
NPI:1629083084
Name:WILDER, SANDRA (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S. SOLANO
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:575-527-7900
Mailing Address - Fax:575-571-4872
Practice Address - Street 1:1900 E. 10TH STREET
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:575-437-7404
Practice Address - Fax:575-439-2860
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0069272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53227000Medicaid
NM18677037Medicaid