Healthcare Provider Details

I. General information

NPI: 1790484889
Provider Name (Legal Business Name): WILD ROOTS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 ROBERT ST
CODY WY
82414-9268
US

IV. Provider business mailing address

PO BOX 2772
CODY WY
82414-2772
US

V. Phone/Fax

Practice location:
  • Phone: 307-899-2492
  • Fax:
Mailing address:
  • Phone: 307-899-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAMAICA SANTOS MOULTON
Title or Position: OWNER
Credential: LPC
Phone: 307-254-5048