Healthcare Provider Details

I. General information

NPI: 1407584659
Provider Name (Legal Business Name): MAXINE WYLDE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 MONUMENT AVE STE 314
RICHMOND VA
23220-2618
US

IV. Provider business mailing address

2501 MONUMENT AVE STE 314
RICHMOND VA
23220-2618
US

V. Phone/Fax

Practice location:
  • Phone: 804-997-5652
  • Fax:
Mailing address:
  • Phone: 804-997-5652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015765
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: