Provider Demographics
NPI:1912888165
Name:WILDE, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 FIRST AVE
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1334
Practice Address - Country:US
Practice Address - Phone:215-645-2684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist