Healthcare Provider Details

I. General information

NPI: 1285559435
Provider Name (Legal Business Name): WILD HEART WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 E STUART ST STE 4104
FORT COLLINS CO
80525-1173
US

IV. Provider business mailing address

1136 E STUART ST STE 4104
FORT COLLINS CO
80525-1173
US

V. Phone/Fax

Practice location:
  • Phone: 970-590-6479
  • Fax:
Mailing address:
  • Phone: 970-590-6479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN KONTZ
Title or Position: COUNSELOR
Credential: LPCC
Phone: 970-590-6479