1609425073 NPI number — BRIANNA WILDE MSW, LICSW

Table of content: BRIANNA WILDE MSW, LICSW (NPI 1609425073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609425073 NPI number — BRIANNA WILDE MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDE
Provider First Name:
BRIANNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COUNSELING, LLC
Provider Other First Name:
FREE TO BE YOU
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609425073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
848 E WOODRUMTOWN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25951-4627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-660-7977
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 SUMMERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25951-2221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-712-2588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  DP00945261 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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