Healthcare Provider Details

I. General information

NPI: 1891629051
Provider Name (Legal Business Name): DBA WILD ROOTS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 S 1100 E STE B
SALT LAKE CITY UT
84105-2493
US

IV. Provider business mailing address

1512 S 1100 E STE B
SALT LAKE CITY UT
84105-2493
US

V. Phone/Fax

Practice location:
  • Phone: 801-231-0946
  • Fax:
Mailing address:
  • Phone: 801-231-0946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARTHA KATALIN WYLD
Title or Position: OWNER
Credential: CMHC
Phone: 801-231-0946