MEDICARE: DIANA WILD

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	101YP1600X	Pastoral Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1548626401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA WILD

Provider Business Mailing Address
First Line	:	823 CARROLL ST
Second Line	:	SUITE B
City	:	MANDEVILLE
State	:	LA
Zip	:	70448-5126
Country	:	US
Telephone Number	:	985-674-0488
Fax Number	:	985-674-0336

Provider Business Practice Location Address
First Line	:	823 CARROLL ST
Second Line	:	SUITE B
City	:	MANDEVILLE
State	:	LA
Zip	:	70448-5126
Country	:	US
Telephone Number	:	985-674-0488
Fax Number	:	985-674-0336

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

Provider Enumeration Date	:	01/07/2016
Last Update Date	:	01/07/2016

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Directions to “ DIANA WILD ” Practice Location

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