Provider Demographics
NPI:1740723659
Name:WILDER, CARMELA (LMSW)
Entity type:Individual
Prefix:
First Name:CARMELA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-465-5330
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-465-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-24
Last Update Date:2016-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010628111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical