Provider Demographics
NPI:1003121898
Name:WILDES, CRYSTAL (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WILDES
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 W 122ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2075
Mailing Address - Country:US
Mailing Address - Phone:303-853-3500
Mailing Address - Fax:
Practice Address - Street 1:8931 HURON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-6806
Practice Address - Country:US
Practice Address - Phone:303-853-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004027103TC0700X
IL178006437101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000154871Medicaid