Provider Demographics
NPI:1174158224
Name:WILDE, MEGHAN ELIZABETH
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ELIZABETH
Last Name:WILDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:ELIZABETH WILDE
Other - Last Name:ROWLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6745 MIAMI LAKES DR APT 228
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-8110
Mailing Address - Country:US
Mailing Address - Phone:786-858-4500
Mailing Address - Fax:
Practice Address - Street 1:1515 NW 167TH ST STE 180
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-5145
Practice Address - Country:US
Practice Address - Phone:786-923-3468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17569101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor