Provider Demographics
NPI:1114352960
Name:WILD, MARGARET NELL (PHD, MS, MFTI)
Entity Type:Individual
Prefix:DR
First Name:MARGARET
Middle Name:NELL
Last Name:WILD
Suffix:
Gender:F
Credentials:PHD, MS, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 DURANGO RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3216
Mailing Address - Country:US
Mailing Address - Phone:951-367-4446
Mailing Address - Fax:951-827-6439
Practice Address - Street 1:51 W OLIVE AVE
Practice Address - Street 2:205 STATE STREET
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5243
Practice Address - Country:US
Practice Address - Phone:951-793-1078
Practice Address - Fax:909-335-7330
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 61023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist