Healthcare Provider Details

I. General information

NPI: 1023666047
Provider Name (Legal Business Name): CARI GWENDOLYN WILD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N BROADWAY
GREEN BAY WI
54303-3426
US

IV. Provider business mailing address

W9124 SAWMILL RD
BLANCHARDVILLE WI
53516-9603
US

V. Phone/Fax

Practice location:
  • Phone: 920-437-7206
  • Fax:
Mailing address:
  • Phone: 608-558-8823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11988-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: