Healthcare Provider Details

I. General information

NPI: 1063603652
Provider Name (Legal Business Name): ELEANOR KAY WILDER LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SOQUEL AVE SUITE 240
SANTA CRUZ CA
95062-2336
US

IV. Provider business mailing address

327 ALAMO AVE
SANTA CRUZ CA
95060-3005
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-1531
  • Fax:
Mailing address:
  • Phone: 831-425-1531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberMFC47911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: