Provider Demographics
NPI:1295122067
Name:WILDE, JANICE MARY (MS)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:MARY
Last Name:WILDE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 16TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-656-1550
Mailing Address - Fax:320-253-9735
Practice Address - Street 1:529 16TH AVE N
Practice Address - Street 2:
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-656-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health