Provider Demographics
NPI:1053683011
Name:WILD, WENDELL (LCSW)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2885 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-1736
Mailing Address - Country:US
Mailing Address - Phone:716-816-4259
Mailing Address - Fax:
Practice Address - Street 1:2885 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1736
Practice Address - Country:US
Practice Address - Phone:716-884-4478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR033870-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY166001554Medicaid