MEDICARE: LAQUITTA ANTIONETTE 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	104100000X	Social Worker	2019031990	MO

General Provider Information

NPI Number	:	1437692654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAQUITTA ANTIONETTE WILDER LCSW

Provider Business Mailing Address
First Line	:	3117 NORWOOD AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-1037
Country	:	US
Telephone Number	:	314-450-0923
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 WELDON PKWY
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-3102
Country	:	US
Telephone Number	:	314-417-5075
Fax Number	:

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

Provider Enumeration Date	:	11/19/2016
Last Update Date	:	11/13/2024

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