Healthcare Provider Details

I. General information

NPI: 1366478323
Provider Name (Legal Business Name): DAVID WILDER LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 3RD ST STE 101
LANGLEY WA
98260-9229
US

IV. Provider business mailing address

PO BOX 842
LANGLEY WA
98260-0842
US

V. Phone/Fax

Practice location:
  • Phone: 360-341-3562
  • Fax: 360-221-2515
Mailing address:
  • Phone: 360-341-3562
  • Fax: 360-221-2515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005030
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: