MEDICARE: KATHLEEN WILD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	5457 C	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023061801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN WILD LCSW

Provider Business Mailing Address
First Line	:	3016 W CHARLESTON BLVD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1973
Country	:	US
Telephone Number	:	206-734-5445
Fax Number	:	702-895-4014

Provider Business Practice Location Address
First Line	:	6375 W CHARLESTON BLVD
Second Line	:	STE A100
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1139
Country	:	US
Telephone Number	:	702-253-0818
Fax Number	:	702-253-9625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	05/14/2021

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Directions to “ KATHLEEN WILD LCSW” Practice Location

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