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: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2378 WILSHIRE BLVD
MOUND MN
55364-1652
US

IV. Provider business mailing address

5687 MAIN ST W
MAPLE PLAIN MN
55359-9533
US

V. Phone/Fax

Practice location:
  • Phone: 570-903-1133
  • Fax:
Mailing address:
  • Phone: 570-903-1133
  • 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: 570-903-1133