Healthcare Provider Details

I. General information

NPI: 1104646900
Provider Name (Legal Business Name): CLIO WILDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE STE 7M
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1001 POTRERO AVE STE 7M
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-5540
  • Fax:
Mailing address:
  • Phone: 628-206-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW124012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: