Provider Demographics
NPI:1710471909
Name:WILDE, RACHEL
Entity Type:Individual
Prefix:MISS
First Name:RACHEL
Middle Name:
Last Name:WILDE
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 1:5327 BRADBURY CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-2518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6951 PISTOL RANGE RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9601
Practice Address - Country:US
Practice Address - Phone:813-814-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician