Provider Demographics
NPI:1588225585
Name:WILD, ROBERT LAE (LICSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAE
Last Name:WILD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MIDDLESEX AVE # 1149
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1105
Mailing Address - Country:US
Mailing Address - Phone:508-203-1896
Mailing Address - Fax:
Practice Address - Street 1:47 THORNDIKE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1799
Practice Address - Country:US
Practice Address - Phone:617-405-5495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW11215181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical