Provider Demographics
NPI:1659581833
Name:WILDE, ALIZA MARGARETE (MSW,ASW)
Entity Type:Individual
Prefix:MS
First Name:ALIZA
Middle Name:MARGARETE
Last Name:WILDE
Suffix:
Gender:F
Credentials:MSW,ASW
Other - Prefix:MS
Other - First Name:ALIZA
Other - Middle Name:MARGARETE
Other - Last Name:WILDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW,ASW
Mailing Address - Street 1:921 W AVENUE J
Mailing Address - Street 2:SUITE C
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3443
Mailing Address - Country:US
Mailing Address - Phone:661-949-0131
Mailing Address - Fax:661-729-8912
Practice Address - Street 1:921 W AVENUE J
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0131
Practice Address - Fax:661-729-8912
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW34307101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAACSW-101YM0800XMedicaid