Healthcare Provider Details

I. General information

NPI: 1114586062
Provider Name (Legal Business Name): MICAELA R WILDERMUTH LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICAELA R SANDS

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 SW 28TH ST
TOPEKA KS
66614-2348
US

IV. Provider business mailing address

2015 NW WEST ST
TOPEKA KS
66608-1955
US

V. Phone/Fax

Practice location:
  • Phone: 785-289-1862
  • Fax:
Mailing address:
  • Phone: 785-230-6489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number07311
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11309
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: