Healthcare Provider Details

I. General information

NPI: 1871287847
Provider Name (Legal Business Name): WILD SEED PSYCH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 09/06/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BEARCAMP POND RD
SOUTH TAMWORTH NH
03883-3402
US

IV. Provider business mailing address

140 BEARCAMP POND RD
SOUTH TAMWORTH NH
03883-3402
US

V. Phone/Fax

Practice location:
  • Phone: 603-630-7063
  • Fax:
Mailing address:
  • Phone: 603-630-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CYMANDE BAXTER-ROGERS
Title or Position: OWNER, LEAD CLINICIAN
Credential: ARNP
Phone: 603-630-7063