Provider Demographics
NPI:1104539675
Name:WILDER, ALEJANDRA (SUDRC)
Entity type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:
Last Name:WILDER
Suffix:
Gender:
Credentials:SUDRC
Other - Prefix:
Other - First Name:ALEJANDRA
Other - Middle Name:
Other - Last Name:TABOADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:
Practice Address - Street 1:8788 JAMACHA RD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-4035
Practice Address - Country:US
Practice Address - Phone:619-515-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14036101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)