Provider Demographics
NPI:1154159317
Name:WILDER, ANTOINETTE (LMSW)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12170 WASHINGTON CENTER PKWY APT 4303
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3838
Mailing Address - Country:US
Mailing Address - Phone:313-460-8913
Mailing Address - Fax:
Practice Address - Street 1:3200 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1805
Practice Address - Country:US
Practice Address - Phone:646-941-7645
Practice Address - Fax:929-596-7897
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011181491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical