Healthcare Provider Details

I. General information

NPI: 1851102123
Provider Name (Legal Business Name): WILD WILLOW THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 DIVIDE ST
ROCK SPRINGS WY
82901-4813
US

IV. Provider business mailing address

1022 DIVIDE ST
ROCK SPRINGS WY
82901-4813
US

V. Phone/Fax

Practice location:
  • Phone: 307-381-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA MERCER WETZEL
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: MS
Phone: 307-381-6400