Provider Demographics
NPI:1487366035
Name:WILDERMAN, ALYSSA K (LPC, MA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:K
Last Name:WILDERMAN
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15209 S LAKESIDE CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2123
Mailing Address - Country:US
Mailing Address - Phone:630-864-8982
Mailing Address - Fax:
Practice Address - Street 1:1804 N NAPER BLVD STE 250
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8830
Practice Address - Country:US
Practice Address - Phone:630-332-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
IL178020118101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program