Healthcare Provider Details

I. General information

NPI: 1467581363
Provider Name (Legal Business Name): DAVID N WILDE M.A., L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12166 OLD BIG BEND RD STE 307
SAINT LOUIS MO
63122-6844
US

IV. Provider business mailing address

12166 OLD BIG BEND RD STE 204
SAINT LOUIS MO
63122-6836
US

V. Phone/Fax

Practice location:
  • Phone: 314-258-6184
  • Fax:
Mailing address:
  • Phone: 314-822-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006038842
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: