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General NPI Number Information
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NPI Number | 1164235073
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Entity Type | Organization
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Legal Business Name | WILD IRIS WELLNESS LLC
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Dates
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Enumeration Date | 01/27/2025
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 1532 TAOS ST
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City | SANTA FE
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State | NM
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Zip | 87505-3836
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Country | US
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Telephone | 505-234-6151
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 45681
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City | RIO RANCHO
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State | NM
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Zip | 87174-5681
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Country | US
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Telephone | 505-226-1960
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Fax | 505-672-7769
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Authorized Official
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Title or Position | OWNER
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Name | CATHERINE HYDE
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Credential | LCSW
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Telephone | 505-234-6151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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