MEDICARE: MS. ANGELLUN VANESSA WILDER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2176	LA
2	171000000X	Military Health Care Provider	2176	LA

General Provider Information

NPI Number	:	1346416096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELLUN VANESSA WILDER LCSW

Provider Business Mailing Address
First Line	:	4443 PINES RD
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71119-8505
Country	:	US
Telephone Number	:	318-631-3792
Fax Number	:

Provider Business Practice Location Address
First Line	:	3004 KNIGHT ST BLDG 6
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2502
Country	:	US
Telephone Number	:	318-603-6874
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2008
Last Update Date	:	05/02/2008

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