Basic Information
| Provider Information | |||||||||
| NPI: | 1023061801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILD | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3016 W CHARLESTON BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067345445 | ||||||||
| FaxNumber: | 7028954014 | ||||||||
| Practice Location | |||||||||
| Address1: | 6375 W CHARLESTON BLVD | ||||||||
| Address2: | STE A100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022530818 | ||||||||
| FaxNumber: | 7022539625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5457 C | NV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100507624 | 05 | NV | MEDICAID |