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General NPI Number Information
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NPI Number | 1255032926
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Entity Type | Organization
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Legal Business Name | WILDER WELLNESS LLC
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Dates
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Enumeration Date | 03/10/2023
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Last Update Date | 03/10/2023
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Provider Practice Location Address
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Address Line | 20225 JONATHON CT
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City | BEND
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State | OR
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Zip | 97703-8764
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Country | US
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Telephone | 458-206-0904
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Fax |
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Provider Business Mailing Address
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Address Line | 70 SW CENTURY DR STE 100 PMB 1076
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City | BEND
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State | OR
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Zip | 97702
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO, THERAPIST
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Name | KRISTEN ALES
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Credential | MA, LPC
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Telephone | 831-345-2951
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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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