Healthcare Provider Details

I. General information

NPI: 1972449718
Provider Name (Legal Business Name): WILD PEACE INTEGRATIVE WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2354 WAYZATA BOULEVARD W. SUITE A
LONG LAKE MN
55356
US

IV. Provider business mailing address

2354 W WAYZATA BLVD STE A
LONG LAKE MN
55356-2602
US

V. Phone/Fax

Practice location:
  • Phone: 952-260-8330
  • Fax:
Mailing address:
  • Phone: 952-260-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KEELY HEISER
Title or Position: ORGANIZER
Credential: LICSW
Phone: 952-260-8330