Provider Demographics
NPI:1851178214
Name:WILD, LAURA (LMSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-1298
Mailing Address - Country:US
Mailing Address - Phone:845-256-4000
Mailing Address - Fax:
Practice Address - Street 1:1 EUGENE L BROWN DR
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-3942
Practice Address - Country:US
Practice Address - Phone:845-256-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1050941041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool