Provider Demographics
NPI:1669656757
Name:BRENNER WILD, DAYLE ALISON (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:DAYLE
Middle Name:ALISON
Last Name:BRENNER WILD
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-0917
Mailing Address - Country:US
Mailing Address - Phone:516-662-2612
Mailing Address - Fax:
Practice Address - Street 1:900 W END AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3547
Practice Address - Country:US
Practice Address - Phone:516-662-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-25
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 0693171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical