Provider Demographics
NPI:1710131008
Name:WILDE, SUSAN MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:WILDE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SAN PABLO AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-2275
Mailing Address - Country:US
Mailing Address - Phone:510-978-0221
Mailing Address - Fax:
Practice Address - Street 1:1035 SAN PABLO AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2275
Practice Address - Country:US
Practice Address - Phone:510-978-0221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19673103TA0400X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral