Provider Demographics
NPI:1316536451
Name:WILDE, CLEO B (LCSW)
Entity Type:Individual
Prefix:
First Name:CLEO
Middle Name:B
Last Name:WILDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 LEE HWY STE 110
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2452
Mailing Address - Country:US
Mailing Address - Phone:423-648-4951
Mailing Address - Fax:
Practice Address - Street 1:6400 LEE HWY STE 110
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2452
Practice Address - Country:US
Practice Address - Phone:423-648-4951
Practice Address - Fax:423-490-0410
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TN90161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker