Provider Demographics
NPI:1477171866
Name:WYLD, MARTHA KATALIN (LCMHC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:KATALIN
Last Name:WYLD
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7069 S HIGHLAND DR STE 115
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3731
Mailing Address - Country:US
Mailing Address - Phone:801-231-0946
Mailing Address - Fax:
Practice Address - Street 1:7069 S HIGHLAND DR STE 115
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3731
Practice Address - Country:US
Practice Address - Phone:801-231-0946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-11
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11829498-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health