MEDICARE: GAIL WYLDE

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	LCSW81197	CA

General Provider Information

NPI Number	:	1326440082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL WYLDE

Provider Business Mailing Address
First Line	:	3835 N FREEWAY BLVD STE 100
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1954
Country	:	US
Telephone Number	:	916-576-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 FRONT ST STE 220
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-4536
Country	:	US
Telephone Number	:	831-325-3971
Fax Number	:

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

Provider Enumeration Date	:	09/24/2014
Last Update Date	:	01/10/2024

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Directions to “ GAIL WYLDE ” Practice Location

Language	Start Address	Practice Location

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