Provider Demographics
NPI:1013182658
Name:WILDE, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 MISSION AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-6106
Mailing Address - Country:US
Mailing Address - Phone:415-457-6964
Mailing Address - Fax:
Practice Address - Street 1:914 MISSION AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-6106
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health