Provider Demographics
NPI:1528552049
Name:WILDER, PATRICKLYRA AWEN (LMFT)
Entity type:Individual
Prefix:
First Name:PATRICKLYRA
Middle Name:AWEN
Last Name:WILDER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 CEDROS AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2839
Mailing Address - Country:US
Mailing Address - Phone:805-403-8729
Mailing Address - Fax:
Practice Address - Street 1:4501 CEDROS AVE UNIT 101
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2839
Practice Address - Country:US
Practice Address - Phone:805-335-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98562106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist