Healthcare Provider Details

I. General information

NPI: 1164235073
Provider Name (Legal Business Name): WILD IRIS WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 TAOS ST
SANTA FE NM
87505-3836
US

IV. Provider business mailing address

PO BOX 45681
RIO RANCHO NM
87174-5681
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-6151
  • Fax:
Mailing address:
  • Phone: 505-226-1960
  • Fax: 505-672-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE HYDE
Title or Position: OWNER
Credential: LCSW
Phone: 505-234-6151