Provider Demographics
NPI:1912305558
Name:WILDER, VANESSA LASHALLE (LPC)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:LASHALLE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:LASHALLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2677 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2562
Mailing Address - Country:US
Mailing Address - Phone:313-300-5045
Mailing Address - Fax:
Practice Address - Street 1:9315 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:313-450-4512
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-14
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011048101YP2500X
MI640101048101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional