Healthcare Provider Details

I. General information

NPI: 1699104257
Provider Name (Legal Business Name): JO EVELYN WILDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9599 SUMMER HILL RD
CALIFORNIA KY
41007-9055
US

IV. Provider business mailing address

4380 BATON ROUGE RD
WILLIAMSTOWN KY
41097-3067
US

V. Phone/Fax

Practice location:
  • Phone: 859-635-0500
  • Fax: 859-635-0504
Mailing address:
  • Phone: 859-635-0500
  • Fax: 859-635-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1712
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: