Provider Demographics
NPI:1104143213
Name:WILDE, TRACY LEIGH (BA)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEIGH
Last Name:WILDE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:LEIGH
Other - Last Name:BIGBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:7015 S DOGWOOD PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-2071
Mailing Address - Country:US
Mailing Address - Phone:918-630-3566
Mailing Address - Fax:
Practice Address - Street 1:7015 S DOGWOOD PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-2071
Practice Address - Country:US
Practice Address - Phone:918-630-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst