Healthcare Provider Details

I. General information

NPI: 1255820205
Provider Name (Legal Business Name): WILD MAGNOLIA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 11/13/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 4TH ST NW STE H-5
LOS RANCHOS NM
87107-5800
US

IV. Provider business mailing address

5023 5TH ST NW
ALBUQUERQUE NM
87107-3803
US

V. Phone/Fax

Practice location:
  • Phone: 505-274-0112
  • Fax:
Mailing address:
  • Phone: 505-274-0126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0139371
License Number StateNM

VIII. Authorized Official

Name: ASHLEY SUSAN MCKENNA
Title or Position: OWNER
Credential: LPCC
Phone: 505-274-0112