Provider Demographics
NPI:1750161683
Name:WILDER, NAKIA SHANTE' (LMSW)
Entity type:Individual
Prefix:MS
First Name:NAKIA
Middle Name:SHANTE'
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 1:4172 EDENBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5193
Mailing Address - Country:US
Mailing Address - Phone:770-231-5412
Mailing Address - Fax:
Practice Address - Street 1:4172 EDENBROOKE CIR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5193
Practice Address - Country:US
Practice Address - Phone:770-231-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW011324101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health