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General NPI Number Information
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NPI Number | 1003727033
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Entity Type | Organization
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Legal Business Name | WAYWARD & WILD COLLECTIVE, LLC
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Dates
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Enumeration Date | 09/16/2026
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Last Update Date | 09/16/2026
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Provider Practice Location Address
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Address Line | 1101 READING AVE LOWR
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City | BOYERTOWN
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State | PA
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Zip | 19512-7549
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Country | US
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Telephone | 484-300-8290
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 READING AVE LOWR
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City | BOYERTOWN
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State | PA
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Zip | 19512-7549
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Country | US
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Telephone | 484-300-8290
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | SHANNON COLGAN
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Credential | LPC
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Telephone | 484-300-8290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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