Healthcare Provider Details

I. General information

NPI: 1386909646
Provider Name (Legal Business Name): JAMES DEMARIS WILDE MA, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N MICHIGAN AVE STE 1430
CHICAGO IL
60601-7653
US

IV. Provider business mailing address

3073 W PUDU ST
MERIDIAN ID
83646-5414
US

V. Phone/Fax

Practice location:
  • Phone: 312-971-3457
  • Fax:
Mailing address:
  • Phone: 208-803-2363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0011242
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401226171
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMHC.LH.61060559
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5521
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: