Provider Demographics
NPI:1801972195
Name:MANN-WILDER, EVELYN STEPHANIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:STEPHANIE
Last Name:MANN-WILDER
Suffix:
Gender:F
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:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-0405
Mailing Address - Country:US
Mailing Address - Phone:530-340-0142
Mailing Address - Fax:530-842-9668
Practice Address - Street 1:409 W. CENTER ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-2418
Practice Address - Country:US
Practice Address - Phone:530-340-0142
Practice Address - Fax:530-842-9668
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS208351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26079ZMedicare PIN