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Provider Information for 1336664572


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ROSHELLE MAE WILDER MSW


Sex: Female

NPI: 1336664572
Last Updated: 2017-08-09
Certification Date:

Details

NameValue
NPI1336664572
Enumeration Date2017-08-09
NPI TypeNPI-1 Individual
Sole ProprietorNO
StatusActive
Mailing Address 2801 NE 183RD ST
AVENTURA, FL 33160-2100
United States

Phone: | Fax:
 
Primary Practice Address 1825 NW 167TH ST STE 102
MIAMI GARDENS, FL 33056-4838
United States

Phone: 305-624-7450 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDFL1609301654
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 1041C0700X - Social Worker - Clinical