Provider Demographics
NPI:1023645900
Name:WYLD, TOBI (LCSW)
Entity type:Individual
Prefix:
First Name:TOBI
Middle Name:
Last Name:WYLD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TOBI
Other - Middle Name:
Other - Last Name:WYLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:6606 N GLENWOOD AVE APT G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5607
Mailing Address - Country:US
Mailing Address - Phone:224-241-0037
Mailing Address - Fax:
Practice Address - Street 1:6606 N GLENWOOD AVE APT G
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-5607
Practice Address - Country:US
Practice Address - Phone:224-241-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490214651041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149021465OtherSTATE OF ILLINOIS