Provider Demographics
NPI:1578393278
Name:WILD, TIFFANY A
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:WILD
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 1:15455 CONWAY RD STE 117
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2022
Mailing Address - Country:US
Mailing Address - Phone:636-466-3077
Mailing Address - Fax:
Practice Address - Street 1:15455 CONWAY RD STE 117
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2022
Practice Address - Country:US
Practice Address - Phone:636-466-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022037460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health