Provider Demographics
NPI:1710140447
Name:WILDE, BRANDON J (CMHC)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:J
Last Name:WILDE
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11086 S GRAPE ARBOR PL
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-6708
Mailing Address - Country:US
Mailing Address - Phone:719-588-6976
Mailing Address - Fax:
Practice Address - Street 1:4460 CENTRAL WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-237-1711
Practice Address - Fax:208-237-5192
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2018-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9471002-6004101YM0800X
IDLPC3887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807197600Medicaid