Basic Information
| Provider Information | |||||||||
| NPI: | 1699943175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILD | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 E 39TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924041825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095288274 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 164 W HOSPITALITY LN | ||||||||
| Address2: | SUITE 1-A | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098911880 | ||||||||
| FaxNumber: | 9098911888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2008 | ||||||||
| LastUpdateDate: | 02/18/2008 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.