MEDICARE: ELIZABETH WILD LCSW

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	149023240	IL

General Provider Information

NPI Number	:	1649852526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH WILD LCSW

Provider Business Mailing Address
First Line	:	2772 JAMAR TRL APT 206
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521-2373
Country	:	US
Telephone Number	:	618-558-0644
Fax Number	:

Provider Business Practice Location Address
First Line	:	3008 HAPPY LANDING DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6259
Country	:	US
Telephone Number	:	630-428-7890
Fax Number	:

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

Provider Enumeration Date	:	04/21/2021
Last Update Date	:	04/21/2021

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