Basic Information
| Provider Information | |||||||||
| NPI: | 1699818245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILD | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 WAYNE AVE | ||||||||
| Address2: | #4 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946061133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283885 | ||||||||
| FaxNumber: | 5106322576 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 52ND ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283885 | ||||||||
| FaxNumber: | 5106322576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 37077 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.