Provider Demographics
NPI:1124038500
Name:DE WILDT, THOMAS L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:L
Last Name:DE WILDT
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 1:15525 POMERADO RD
Mailing Address - Street 2:SUITE A-7
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2435
Mailing Address - Country:US
Mailing Address - Phone:858-279-1223
Mailing Address - Fax:858-673-8519
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE A-7
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-279-1223
Practice Address - Fax:858-673-8519
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 93901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical