Provider Demographics
NPI:1760804744
Name:WILDE, WINSTON (MFC)
Entity Type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:MFC
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 3604
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-3604
Mailing Address - Country:US
Mailing Address - Phone:323-691-4071
Mailing Address - Fax:
Practice Address - Street 1:134 MONTANO LN
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6495
Practice Address - Country:US
Practice Address - Phone:323-691-4071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39060106H00000X
NMCMF0184921106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist