MEDICARE: MRS. KELLI WILD MSW, RCSWI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1225453806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLI WILD MSW, RCSWI

Provider Business Mailing Address
First Line	:	7069 OLD PASCO RD
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-3328
Country	:	US
Telephone Number	:	813-777-5961
Fax Number	:

Provider Business Practice Location Address
First Line	:	4144 N ARMENIA AVE STE 210
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6447
Country	:	US
Telephone Number	:	813-777-5961
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	07/18/2014

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