Provider Demographics
NPI:1982901120
Name:WILDER, SONJA ANN (CADC I)
Entity Type:Individual
Prefix:MRS
First Name:SONJA
Middle Name:ANN
Last Name:WILDER
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:MS
Other - First Name:SONJA
Other - Middle Name:ANN
Other - Last Name:SCHOBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3647 HIGHWAY 39
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-2612
Mailing Address - Country:US
Mailing Address - Phone:541-884-5244
Mailing Address - Fax:541-884-1105
Practice Address - Street 1:3647 HIGHWAY 39
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-2612
Practice Address - Country:US
Practice Address - Phone:541-884-5244
Practice Address - Fax:541-884-1105
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06-11-52101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136460Medicaid