Provider Demographics
NPI:1336647205
Name:WILDHABER, CAROLYN SUE (CSW-PIP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
Last Name:WILDHABER
Suffix:
Gender:F
Credentials:CSW-PIP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:SUE
Other - Last Name:SCHWEINEFUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:224 ELK STREET
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-755-7710
Mailing Address - Fax:
Practice Address - Street 1:224 ELK STREET
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-755-7710
Practice Address - Fax:605-755-7719
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD34421041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical