Provider Demographics
NPI:1861156473
Name:WILDER, ELLICIA (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:ELLICIA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 W HISTORIC MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:414-383-9526
Mailing Address - Fax:
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:414-383-9526
Practice Address - Fax:414-671-6606
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18729-130101YA0400X
WI4482-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)