Healthcare Provider Details

I. General information

NPI: 1023645900
Provider Name (Legal Business Name): TOBI WYLD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TOBI WYLD LCSW

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6606 N GLENWOOD AVE APT G
CHICAGO IL
60626-5607
US

IV. Provider business mailing address

6606 N GLENWOOD AVE APT G
CHICAGO IL
60626-5607
US

V. Phone/Fax

Practice location:
  • Phone: 224-241-0037
  • Fax:
Mailing address:
  • Phone: 224-241-0037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: