Provider Demographics
NPI:1053434027
Name:WILDFIELD, JOAN R (MA, LMHC)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:R
Last Name:WILDFIELD
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2742
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-2742
Mailing Address - Country:US
Mailing Address - Phone:360-714-0830
Mailing Address - Fax:360-714-8170
Practice Address - Street 1:119 N COMMERCIAL ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4446
Practice Address - Country:US
Practice Address - Phone:360-714-0830
Practice Address - Fax:360-714-8170
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA129881100000OtherPREMERA BLUE CROSS
WA17227OtherREGENCE BLUE SHIELD
WA827230OtherDDD
WA8924300OtherCRIME VICTIMS COMPENSATIO
WALH00004307OtherWASHINGTON STATE LICENSE