Provider Demographics
NPI:1831928183
Name:WILRIDGE, IMANIECE LAVAN
Entity type:Individual
Prefix:
First Name:IMANIECE
Middle Name:LAVAN
Last Name:WILRIDGE
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 1:15050 COPPER GROVE BLVD APT 2203
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-2469
Mailing Address - Country:US
Mailing Address - Phone:281-730-2035
Mailing Address - Fax:
Practice Address - Street 1:15050 COPPER GROVE BLVD
Practice Address - Street 2:APT 2203
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095
Practice Address - Country:US
Practice Address - Phone:281-730-2035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician