Healthcare Provider Details

I. General information

NPI: 1477171866
Provider Name (Legal Business Name): MARTHA KATALIN WYLD LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2020
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7069 S HIGHLAND DR STE 115
COTTONWOOD HEIGHTS UT
84121-3731
US

IV. Provider business mailing address

7069 S HIGHLAND DR STE 115
COTTONWOOD HEIGHTS UT
84121-3731
US

V. Phone/Fax

Practice location:
  • Phone: 801-231-0946
  • Fax:
Mailing address:
  • Phone: 801-231-0946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11829498-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: