Provider Demographics
NPI:1538752159
Name:WYLDE, ELIZABETH T
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:T
Last Name:WYLDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W BIG BEAVER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4725
Mailing Address - Country:US
Mailing Address - Phone:734-325-9531
Mailing Address - Fax:
Practice Address - Street 1:13 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2617
Practice Address - Country:US
Practice Address - Phone:734-325-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011090581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty