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General NPI Number Information
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NPI Number | 1174359012
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Entity Type | Organization
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Legal Business Name | WILD NORTH COUNSELING LLC
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Dates
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Enumeration Date | 09/09/2024
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 41 DEPOT ST STE 204
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City | BRIDGTON
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State | ME
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Zip | 04009-2298
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Country | US
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Telephone | 207-803-8735
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Fax |
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Provider Business Mailing Address
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Address Line | 41 DEPOT ST STE 204
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City | BRIDGTON
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State | ME
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Zip | 04009-2298
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Country | US
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Telephone | 207-803-8735
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TIGHE BLACKADAR
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Credential | LCSW
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Telephone | 207-803-8735
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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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