MEDICARE: MARTHA KATALIN WYLD LCMHC

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	11829498-6004	UT

General Provider Information

NPI Number	:	1477171866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA KATALIN WYLD LCMHC

Provider Business Mailing Address
First Line	:	7069 S HIGHLAND DR STE 115
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3731
Country	:	US
Telephone Number	:	801-231-0946
Fax Number	:

Provider Business Practice Location Address
First Line	:	7069 S HIGHLAND DR STE 115
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3731
Country	:	US
Telephone Number	:	801-231-0946
Fax Number	:

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

Provider Enumeration Date	:	07/11/2020
Last Update Date	:	09/09/2021

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