MEDICARE: EMILY WILDE

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		WI

General Provider Information

NPI Number	:	1790640571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY WILDE

Provider Business Mailing Address
First Line	:	W57N727 HAWTHORNE AVE
Second Line	:
City	:	CEDARBURG
State	:	WI
Zip	:	53012-1452
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10535 N PORT WASHINGTON RD STE 204
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5560
Country	:	US
Telephone Number	:	262-421-5101
Fax Number	:

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

Provider Enumeration Date	:	12/23/2025
Last Update Date	:	12/23/2025

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Directions to “ EMILY WILDE ” Practice Location

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