=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003604935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAEGAN LILLIAN WILD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2025
-----------------------------------------------------
Last Update Date | 04/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1073 N BENSON RD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-5171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-254-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 149 BEACON MANOR RD
-----------------------------------------------------
City | NAUGATUCK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06770-4914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-915-3074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------