Provider Demographics
NPI:1194324947
Name:WILDS, ROBYN ANGELA (SUDP)
Entity type:Individual
Prefix:
First Name:ROBYN
Middle Name:ANGELA
Last Name:WILDS
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-8210
Mailing Address - Country:US
Mailing Address - Phone:253-280-9897
Mailing Address - Fax:253-280-9870
Practice Address - Street 1:1415 CENTER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-8210
Practice Address - Country:US
Practice Address - Phone:253-280-9897
Practice Address - Fax:253-280-9870
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61046261101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61046261Medicaid