Provider Demographics
NPI:1467581363
Name:WILDE, DAVID N (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:N
Last Name:WILDE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12166 OLD BIG BEND RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6836
Mailing Address - Country:US
Mailing Address - Phone:314-822-8888
Mailing Address - Fax:
Practice Address - Street 1:12166 OLD BIG BEND RD
Practice Address - Street 2:STE 307
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6844
Practice Address - Country:US
Practice Address - Phone:314-258-6184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006038842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional