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NPI Code Detail

MEDICARE: MS. LISA WILD MFT

MEDICARE: MS. LISA WILD MFT
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
1106H00000XMarriage & Family Therapist37077CA

General Provider Information

NPI Number : 1699818245
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. LISA WILD MFT
Provider Business Mailing Address
First Line : 420 WAYNE AVE APT 4
Second Line :
City : OAKLAND
State : CA
Zip : 94606-1133
Country : US
Telephone Number : 510-428-3885
Fax Number : 510-632-2576
Provider Business Practice Location Address
First Line : 770 53RD ST
Second Line :
City : OAKLAND
State : CA
Zip : 94609-1814
Country : US
Telephone Number : 510-428-3441
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/14/2007
Last Update Date : 11/05/2025

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