Provider Demographics
NPI:1174843304
Name:WILDE, CATHLEEN S (MA, LPCC)
Entity Type:Individual
Prefix:MS
First Name:CATHLEEN
Middle Name:S
Last Name:WILDE
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TAFT RD
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-7907
Mailing Address - Country:US
Mailing Address - Phone:505-269-2429
Mailing Address - Fax:
Practice Address - Street 1:3321 CANDELARIA RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1966
Practice Address - Country:US
Practice Address - Phone:505-269-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0070981101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional