Healthcare Provider Details

I. General information

NPI: 1811613599
Provider Name (Legal Business Name): WILDWOOD MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 NW 1ST AVE STE 4
GRAND RAPIDS MN
55744-2749
US

IV. Provider business mailing address

204 NW 1ST AVE STE 4
GRAND RAPIDS MN
55744-2749
US

V. Phone/Fax

Practice location:
  • Phone: 218-301-6278
  • Fax:
Mailing address:
  • Phone:
  • 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: TABBATHA LITCHKE HERDMAN
Title or Position: LPCC
Credential:
Phone: 218-301-6278