Provider Demographics
NPI:1649852526
Name:WILD, ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:2772 JAMAR TRL APT 206
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-2373
Mailing Address - Country:US
Mailing Address - Phone:618-558-0644
Mailing Address - Fax:
Practice Address - Street 1:3008 HAPPY LANDING DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6259
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490232401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical