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General NPI Number Information
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NPI Number | 1124186382
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Entity Type | Individual
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Provider Name | MARJORIE WILDE M.S., LMHC
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Gender | Female
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1000 EXECUTIVE DR SUITE 9
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City | OVIEDO
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State | FL
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Zip | 32765-8140
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Country | US
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Telephone | 407-971-0266
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Fax |
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Provider Business Mailing Address
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Address Line | 677 SILVER BIRCH PL
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City | LONGWOOD
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State | FL
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Zip | 32750-8424
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Country | US
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Telephone | 407-324-5110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH 2558
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License Number State | FL
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