Individual
DR. BRANDON J WILDE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CMHC
Contact information
Practice address
122 E 1700 S BLDG 3, PROVO, UT 84606-5644
(801) 900-3656
Mailing address
7897 N BROKEN ARROW LN, EAGLE MOUNTAIN, UT 84005-7203
(602) 460-6428
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
9471002-6004
UT
101YM0800X
Mental Health Counselor
Primary
9471022-6044
UT
101YM0800X
Mental Health Counselor
LPC-17502
AZ
101YM0800X
Mental Health Counselor
LPC3887
ID
101YP2500X
Professional Counselor
CP3313-R
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4290476
—
UT
05
—
807197600
—
ID
Enumeration date
07/02/2008
Last updated
09/10/2024
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