Provider Demographics
NPI:1801233192
Name:WILDE, MARK J (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:WILDE
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7051 BROOKLYN BLVD BLDG 120
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1371
Mailing Address - Country:US
Mailing Address - Phone:612-741-8286
Mailing Address - Fax:
Practice Address - Street 1:7051 BROOKLYN BLVD BLDG 120
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1371
Practice Address - Country:US
Practice Address - Phone:612-741-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2333106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist