Provider Demographics
NPI:1295939080
Name:WILD, RANDY (LCPC)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152 S BOWN WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5456
Mailing Address - Country:US
Mailing Address - Phone:541-550-7940
Mailing Address - Fax:541-550-7941
Practice Address - Street 1:3152 S BOWN WAY STE 103
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5456
Practice Address - Country:US
Practice Address - Phone:541-550-7940
Practice Address - Fax:541-550-7941
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1740101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health