Provider Demographics
NPI:1659711877
Name:WILDER, SHAWNTE MICHELE
Entity Type:Individual
Prefix:
First Name:SHAWNTE
Middle Name:MICHELE
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 1:318 TAYLOR POND RD
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-3416
Mailing Address - Country:US
Mailing Address - Phone:803-524-3224
Mailing Address - Fax:
Practice Address - Street 1:654 MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7403
Practice Address - Country:US
Practice Address - Phone:706-595-2548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor