Provider Demographics
NPI:1750357893
Name:WILDE, JAMES (LCSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 SILVER BIRCH PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-8424
Mailing Address - Country:US
Mailing Address - Phone:407-644-7593
Mailing Address - Fax:407-628-0773
Practice Address - Street 1:2100 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1862
Practice Address - Country:US
Practice Address - Phone:407-644-7593
Practice Address - Fax:407-628-0773
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW19581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3032OtherBCBSF PROVIDER NUMBER
FLZ3032OtherBCBSF PROVIDER NUMBER