Healthcare Provider Details

I. General information

NPI: 1366356917
Provider Name (Legal Business Name): ELIJAH WILD LMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 NE GILMAN BLVD STE 201
ISSAQUAH WA
98027-2906
US

IV. Provider business mailing address

295 NE GILMAN BLVD STE 201
ISSAQUAH WA
98027-2906
US

V. Phone/Fax

Practice location:
  • Phone: 425-677-7404
  • Fax: 425-677-7753
Mailing address:
  • Phone: 425-677-7404
  • Fax: 425-677-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.70163233
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: