Provider Demographics
NPI:1023382561
Name:WILDE, PATRICIA M (LICSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:M
Last Name:WILDE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MIDDLESEX ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1828
Mailing Address - Country:US
Mailing Address - Phone:781-910-8328
Mailing Address - Fax:
Practice Address - Street 1:7 WINN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-2871
Practice Address - Country:US
Practice Address - Phone:781-910-8328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10255071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical