Provider Demographics
NPI:1821120353
Name:WILD, P. DIANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:P.
Middle Name:DIANE
Last Name:WILD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4122
Mailing Address - Country:US
Mailing Address - Phone:303-443-3174
Mailing Address - Fax:
Practice Address - Street 1:2315 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4122
Practice Address - Country:US
Practice Address - Phone:303-443-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9790321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO979032OtherSTATE LICENSE NUMBER