Provider Demographics
NPI:1689436511
Name:WILDER, SORAYA QASSIM
Entity Type:Individual
Prefix:
First Name:SORAYA
Middle Name:QASSIM
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23622 CALABASAS RD STE 321
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1549
Mailing Address - Country:US
Mailing Address - Phone:818-336-1437
Mailing Address - Fax:
Practice Address - Street 1:23622 CALABASAS RD STE 321
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1549
Practice Address - Country:US
Practice Address - Phone:818-336-1437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15373101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional