Healthcare Provider Details

I. General information

NPI: 1912718883
Provider Name (Legal Business Name): WILD HEART THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2025
Last Update Date: 01/18/2025
Certification Date: 01/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4537 N LEAVITT ST APT 1
CHICAGO IL
60625-1673
US

IV. Provider business mailing address

4537 N LEAVITT ST APT 1
CHICAGO IL
60625-1673
US

V. Phone/Fax

Practice location:
  • Phone: 574-276-5018
  • Fax:
Mailing address:
  • Phone: 574-276-5018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARY KATHLEEN REAGAN
Title or Position: THERAPIST
Credential: LLC
Phone: 574-276-5018