Provider Demographics
NPI:1649657149
Name:HEATH, WILDER (MA, LMFT)
Entity type:Individual
Prefix:MR
First Name:WILDER
Middle Name:
Last Name:HEATH
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 115TH AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6935
Mailing Address - Country:US
Mailing Address - Phone:425-821-1810
Mailing Address - Fax:
Practice Address - Street 1:12025 115TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6935
Practice Address - Country:US
Practice Address - Phone:425-821-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-5546T106H00000X
WAMG60467470106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist