Healthcare Provider Details

I. General information

NPI: 1619872819
Provider Name (Legal Business Name): GROW WILD THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 E 22ND ST N STE D
WICHITA KS
67226-2350
US

IV. Provider business mailing address

401 N BELMONT AVE
WICHITA KS
67208-3810
US

V. Phone/Fax

Practice location:
  • Phone: 316-634-4153
  • Fax:
Mailing address:
  • Phone: 316-203-0741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTINA LEIGH MARVIN
Title or Position: OWNER
Credential: PHD
Phone: 316-204-0741