Healthcare Provider Details

I. General information

NPI: 1174843304
Provider Name (Legal Business Name): CATHLEEN S WILDE MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3321 CANDELARIA RD NE
ALBUQUERQUE NM
87107-1966
US

IV. Provider business mailing address

29 TAFT RD
SANDIA PARK NM
87047-7907
US

V. Phone/Fax

Practice location:
  • Phone: 505-269-2429
  • Fax:
Mailing address:
  • Phone: 505-269-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0070981
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: