Provider Demographics
NPI:1336438795
Name:WILDE, ERIC C (LCSW)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:WILDE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4784 BOSTON POST RD APT B61
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-3022
Mailing Address - Country:US
Mailing Address - Phone:914-336-2274
Mailing Address - Fax:
Practice Address - Street 1:4784 BOSTON POST RD APT B61
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NY
Practice Address - Zip Code:10803-3022
Practice Address - Country:US
Practice Address - Phone:914-336-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075102-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical