Healthcare Provider Details

I. General information

NPI: 1427962414
Provider Name (Legal Business Name): WILDHAVEN THERAPY, A LICENSED CLINICAL SOCIAL WORKER CORP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 BELLEVUE AVE STE 201B
OAKLAND CA
94610-4923
US

IV. Provider business mailing address

445 BELLEVUE AVE STE 201B
OAKLAND CA
94610-4923
US

V. Phone/Fax

Practice location:
  • Phone: 510-824-8218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARY FLEISCH
Title or Position: CEO
Credential: LCSW
Phone: 510-829-3663