Provider Demographics
NPI:1548626401
Name:WILD, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:WILD
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 1:823 CARROLL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5126
Mailing Address - Country:US
Mailing Address - Phone:985-674-0488
Mailing Address - Fax:985-674-0336
Practice Address - Street 1:823 CARROLL ST
Practice Address - Street 2:SUITE B
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5126
Practice Address - Country:US
Practice Address - Phone:985-674-0488
Practice Address - Fax:985-674-0336
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral