Provider Demographics
NPI:1063078947
Name:WILDER, CHAUNTE
Entity type:Individual
Prefix:MS
First Name:CHAUNTE
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1405
Mailing Address - Country:US
Mailing Address - Phone:773-779-5432
Mailing Address - Fax:
Practice Address - Street 1:3317 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2243
Practice Address - Country:US
Practice Address - Phone:708-529-3011
Practice Address - Fax:708-529-3207
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014767101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional