Healthcare Provider Details

I. General information

NPI: 1861233876
Provider Name (Legal Business Name): WILD ORCHID WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 NEW BRITAIN RD
BERLIN CT
06037-1318
US

IV. Provider business mailing address

363 NEW BRITAIN RD
BERLIN CT
06037-1318
US

V. Phone/Fax

Practice location:
  • Phone: 860-614-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MADELINE ORTIZ
Title or Position: OWNER
Credential: LCSW
Phone: 860-614-2222