Provider Demographics
NPI:1770866485
Name:WILDE, TOBIAS ALLEN SR (MSW, LICSW)
Entity type:Individual
Prefix:MR
First Name:TOBIAS
Middle Name:ALLEN
Last Name:WILDE
Suffix:SR
Gender:M
Credentials:MSW, LICSW
Other - Prefix:MR
Other - First Name:TOBIAS
Other - Middle Name:
Other - Last Name:WILDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4422 30TH AVE S APT 309
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8441
Mailing Address - Country:US
Mailing Address - Phone:801-548-8535
Mailing Address - Fax:
Practice Address - Street 1:4422 30TH AVE S APT 309
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8441
Practice Address - Country:US
Practice Address - Phone:801-548-8535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND57971041C0700X
MN249701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical