{
"Npi": {
"NPI": "1891224879",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "WILD GOOSE COUNSELING LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "379 W KATMAI AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SOLDOTNA",
"MailingAddressStateName": "AK",
"MailingAddressPostalCode": "99669-7315",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "907-953-9614",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "198 W MARYDALE AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SOLDOTNA",
"PracticeLocationAddressStateName": "AK",
"PracticeLocationAddressPostalCode": "99669-7501",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "907-953-9614",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/05/2017",
"LastUpdateDate": "06/05/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DAVIS",
"AuthorizedOfficialFirstName": "LYDIA",
"AuthorizedOfficialMiddleName": "ANNA",
"AuthorizedOfficialTitle": "CO-OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LPC. MAC",
"AuthorizedOfficialTelephoneNumber": "907-953-9614",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QM0855X",
"TaxonomyName": "Adolescent and Children Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": "AK",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": "AK",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": null,
"LicenseNumberStateCode": "AK",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}