Healthcare Provider Details

I. General information

NPI: 1205537693
Provider Name (Legal Business Name): WILD & WELL RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E CAMPO DESIERTO RD
TEMPE AZ
85288-1161
US

IV. Provider business mailing address

PO BOX 354
LA VERKIN UT
84745-0354
US

V. Phone/Fax

Practice location:
  • Phone: 435-669-6669
  • Fax:
Mailing address:
  • Phone: 435-669-6669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAM AHQUIN
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYCHOLOGY
Phone: 435-669-6669