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General NPI Number Information
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NPI Number | 1275346330
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Entity Type | Organization
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Legal Business Name | WILD HEART MARRIAGE & FAMILY COUNSELING
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Dates
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Enumeration Date | 01/30/2025
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 126 PROSPECT ST STE 210
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City | PAWTUCKET
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State | RI
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Zip | 02860-4429
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Country | US
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Telephone | 323-839-6925
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 41
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City | NORTH ATTLEBORO
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State | MA
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Zip | 02761-0041
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Country | US
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Telephone | 323-839-6925
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MS. DEJUAN L EVANS
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Credential | LMFT
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Telephone | 323-839-6925
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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