Healthcare Provider Details

I. General information

NPI: 1003727033
Provider Name (Legal Business Name): WAYWARD & WILD COLLECTIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 READING AVE LOWR
BOYERTOWN PA
19512-7549
US

IV. Provider business mailing address

1101 READING AVE LOWR
BOYERTOWN PA
19512-7549
US

V. Phone/Fax

Practice location:
  • Phone: 484-300-8290
  • Fax:
Mailing address:
  • Phone: 484-300-8290
  • 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: SHANNON COLGAN
Title or Position: DIRECTOR
Credential: LPC
Phone: 484-300-8290