Provider Demographics
NPI:1942574512
Name:WILDER, AMBER N (LCPC, LAC)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:N
Last Name:WILDER
Suffix:
Gender:F
Credentials:LCPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N GIBSON RD APT 815
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6734
Mailing Address - Country:US
Mailing Address - Phone:620-804-2942
Mailing Address - Fax:
Practice Address - Street 1:325 N GIBSON RD APT 815
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6734
Practice Address - Country:US
Practice Address - Phone:620-804-2942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS101YA0400X
KS3114101YM0800X
KS3172101YP2500X
NVCP3252-R101YP2500X
KSLAC-1266101YA0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201167420AMedicaid
NV250012412Medicaid