Provider Demographics
NPI:1023666047
Name:WILD, CARI GWENDOLYN
Entity type:Individual
Prefix:
First Name:CARI
Middle Name:GWENDOLYN
Last Name:WILD
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:W9124 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:BLANCHARDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53516-9603
Mailing Address - Country:US
Mailing Address - Phone:608-558-8823
Mailing Address - Fax:
Practice Address - Street 1:2841 6TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1902
Practice Address - Country:US
Practice Address - Phone:608-328-9352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI689156101Y00000X
101YA0400X, 101YM0800X
WI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty