Provider Demographics
NPI:1609425073
Name:WILDE, BRIANNA (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:FREE TO BE YOU
Other - Middle Name:
Other - Last Name:COUNSELING, LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:848 E WOODRUMTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-4627
Mailing Address - Country:US
Mailing Address - Phone:304-660-7977
Mailing Address - Fax:
Practice Address - Street 1:406 SUMMERS ST
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-2221
Practice Address - Country:US
Practice Address - Phone:304-712-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009452611041C0700X
WVCP00945261104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical