Healthcare Provider Details

I. General information

NPI: 1932030954
Provider Name (Legal Business Name): SAM WILDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 QUEBEC ST STE 4300
DENVER CO
80207-2322
US

IV. Provider business mailing address

1500 N GRANT ST STE N
DENVER CO
80203-1859
US

V. Phone/Fax

Practice location:
  • Phone: 720-315-4647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0024720
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: