Provider Demographics
NPI:1457312928
Name:WILDE, OTILIA H (LPC)
Entity Type:Individual
Prefix:
First Name:OTILIA
Middle Name:H
Last Name:WILDE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 STACEY ST
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-3734
Mailing Address - Country:US
Mailing Address - Phone:956-358-0013
Mailing Address - Fax:956-289-7257
Practice Address - Street 1:4701 S SUGAR RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-7012
Practice Address - Country:US
Practice Address - Phone:956-289-7000
Practice Address - Fax:956-289-7257
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16363101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional