Provider Demographics
NPI:1699311670
Name:WILD, CONNER RANDY (SAC)
Entity type:Individual
Prefix:MR
First Name:CONNER
Middle Name:RANDY
Last Name:WILD
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E OLIN AVE STE 275
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1475
Mailing Address - Country:US
Mailing Address - Phone:608-228-0079
Mailing Address - Fax:608-263-9045
Practice Address - Street 1:122 E OLIN AVE STE 275
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1475
Practice Address - Country:US
Practice Address - Phone:608-228-0079
Practice Address - Fax:608-263-9045
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18164-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)