Provider Demographics
NPI:1497372379
Name:WILDS, NAILAH L (LCAT, R-DMT)
Entity Type:Individual
Prefix:
First Name:NAILAH
Middle Name:L
Last Name:WILDS
Suffix:
Gender:F
Credentials:LCAT, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 PROSPECT PARK W # 160
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5802
Mailing Address - Country:US
Mailing Address - Phone:646-667-3802
Mailing Address - Fax:
Practice Address - Street 1:45 E 135TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-2308
Practice Address - Country:US
Practice Address - Phone:646-780-9385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002846101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor