Provider Demographics
NPI:1336619071
Name:WILDER, MERCEDES DARLENE (LICSW)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:DARLENE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 NE 167TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-1566
Mailing Address - Country:US
Mailing Address - Phone:360-442-9166
Mailing Address - Fax:
Practice Address - Street 1:4001 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-1887
Practice Address - Country:US
Practice Address - Phone:360-442-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC605778281041C0700X
WALW608938141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2122263Medicaid