Healthcare Provider Details

I. General information

NPI: 1467436386
Provider Name (Legal Business Name): AMANDA WILDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ALISO DR SE
ALBUQUERQUE NM
87108-2693
US

IV. Provider business mailing address

120 ALISO DR SE
ALBUQUERQUE NM
87108-2693
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-7727
  • Fax:
Mailing address:
  • Phone: 505-750-7727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06735
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: