Provider Demographics
NPI:1053683011
Name:WILD, WENDELL (LCSW-R)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2308
Mailing Address - Country:US
Mailing Address - Phone:716-675-9232
Mailing Address - Fax:716-675-9217
Practice Address - Street 1:70 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2308
Practice Address - Country:US
Practice Address - Phone:716-675-9232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR033870-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY166001554Medicaid