Provider Demographics
NPI:1699002816
Name:LEARY-WILDE, KATHY (MFT)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:LEARY-WILDE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N BLANCHE ST
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-2518
Mailing Address - Country:US
Mailing Address - Phone:805-218-9798
Mailing Address - Fax:805-646-5817
Practice Address - Street 1:611 N BLANCHE ST
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-2518
Practice Address - Country:US
Practice Address - Phone:805-218-9798
Practice Address - Fax:805-646-5817
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47685106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist