Basic Information
| Provider Information | |||||||||
| NPI: | 1235485301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDEN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Practice Location | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2012 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 00835 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00835 | 01 | IA | LICENSE | OTHER |