Provider Demographics
NPI:1629087994
Name:WILDA, THOMAS JOSEPH (SOCIAL WORK, MSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:WILDA
Suffix:
Gender:M
Credentials:SOCIAL WORK, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:655 W IRVING PARK RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3123
Mailing Address - Country:US
Mailing Address - Phone:773-528-8075
Mailing Address - Fax:773-248-3638
Practice Address - Street 1:655 W IRVING PARK RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3123
Practice Address - Country:US
Practice Address - Phone:773-528-8075
Practice Address - Fax:773-248-3638
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL78414Medicare ID - Type UnspecifiedSOCIAL WORK