Provider Demographics
NPI:1518466879
Name:WILD, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 FLORIDA CENTRAL PKWY STE 2008
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-7653
Mailing Address - Country:US
Mailing Address - Phone:407-774-2284
Mailing Address - Fax:407-774-2285
Practice Address - Street 1:740 FLORIDA CENTRAL PKWY STE 2008
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-7653
Practice Address - Country:US
Practice Address - Phone:407-774-2284
Practice Address - Fax:407-774-2285
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health