Provider Demographics
NPI:1629371562
Name:WILD, JOHN MULLANE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MULLANE
Last Name:WILD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 W CHARLESTON BLVD
Mailing Address - Street 2:BLDG. 3A MCT
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1126
Mailing Address - Country:US
Mailing Address - Phone:702-498-5955
Mailing Address - Fax:702-486-5755
Practice Address - Street 1:6161 W CHARLESTON BLVD
Practice Address - Street 2:BLDG. 3A MCT
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-498-5955
Practice Address - Fax:702-486-5755
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01407C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical