Provider Demographics
NPI:1417594367
Name:WILD, MEGAN (LLMSW)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9564 KRESS RD
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-9377
Mailing Address - Country:US
Mailing Address - Phone:734-545-2073
Mailing Address - Fax:
Practice Address - Street 1:9564 KRESS RD
Practice Address - Street 2:
Practice Address - City:PINCKNEY
Practice Address - State:MI
Practice Address - Zip Code:48169-9377
Practice Address - Country:US
Practice Address - Phone:734-545-2073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011025651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical