Provider Demographics
NPI:1750438412
Name:WILDER, KENYA (LCSW)
Entity type:Individual
Prefix:MR
First Name:KENYA
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-1730
Mailing Address - Country:US
Mailing Address - Phone:917-849-9904
Mailing Address - Fax:
Practice Address - Street 1:38 ARCHER RD
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-1730
Practice Address - Country:US
Practice Address - Phone:091-784-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0695401041C0700X
NY064445-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical