Healthcare Provider Details

I. General information

NPI: 1881879922
Provider Name (Legal Business Name): WISDOM TRADITIONS COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W INTERNATIONAL RD STE 27
ANCHORAGE AK
99518-1168
US

IV. Provider business mailing address

401 W INTERNATIONAL RD STE 17
ANCHORAGE AK
99518-1181
US

V. Phone/Fax

Practice location:
  • Phone: 907-562-4540
  • Fax: 907-562-4502
Mailing address:
  • Phone: 907-770-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL W. DEMOLINA
Title or Position: OWNER
Credential: MS, LPC
Phone: 907-562-4540