Healthcare Provider Details

I. General information

NPI: 1770866485
Provider Name (Legal Business Name): TOBIAS ALLEN WILDE SR. MSW, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. TOBIAS WILDE

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 30TH AVE S APT 309
FARGO ND
58104-8441
US

IV. Provider business mailing address

4422 30TH AVE S APT 309
FARGO ND
58104-8441
US

V. Phone/Fax

Practice location:
  • Phone: 801-548-8535
  • Fax:
Mailing address:
  • Phone: 801-548-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5797
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24970
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: