Healthcare Provider Details

I. General information

NPI: 1386253003
Provider Name (Legal Business Name): WILD HOPE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 RIVERSIDE DR STE 117
UPPER ARLNGTN OH
43221-2550
US

IV. Provider business mailing address

3295 KENMORE RD
SHAKER HEIGHTS OH
44122-3456
US

V. Phone/Fax

Practice location:
  • Phone: 614-328-9714
  • Fax:
Mailing address:
  • Phone: 630-404-7833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE PURDOM
Title or Position: OWNER
Credential: LISW
Phone: 630-404-7833