Provider Demographics
NPI:1124186382
Name:WILDE, MARJORIE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 SILVER BIRCH PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-8424
Mailing Address - Country:US
Mailing Address - Phone:407-324-5110
Mailing Address - Fax:
Practice Address - Street 1:1000 EXECUTIVE DR
Practice Address - Street 2:SUITE 9
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8140
Practice Address - Country:US
Practice Address - Phone:407-971-0266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 2558101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health