Provider Demographics
NPI:1538736814
Name:WILDE, ELLIE (PHD)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 3RD AVE W
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-1940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2012 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-6934
Practice Address - Country:US
Practice Address - Phone:425-242-7187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health