Provider Demographics
NPI:1336971878
Name:WILDER, TRICIA LOUISE (LMSW)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:LOUISE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:LOUISE
Other - Last Name:KRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21644 MAYFIELD ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4524
Mailing Address - Country:US
Mailing Address - Phone:248-893-7483
Mailing Address - Fax:
Practice Address - Street 1:44725 GRAND RIVER AVE STE 104
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1024
Practice Address - Country:US
Practice Address - Phone:248-846-8345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010712441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty