Provider Demographics
NPI:1710140447
Name:WILDE, BRANDON J (CMHC)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:J
Last Name:WILDE
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7897 N BROKEN ARROW LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-7203
Mailing Address - Country:US
Mailing Address - Phone:602-460-6428
Mailing Address - Fax:
Practice Address - Street 1:122 E 1700 S BLDG 3
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5644
Practice Address - Country:US
Practice Address - Phone:801-900-3656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9471002-6004101YM0800X
IDLPC3887101YM0800X
AZLPC-17502101YM0800X
NVCP3313-R101YP2500X
UT9471022-6044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807197600Medicaid
UT4290476Medicaid