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General NPI Number Information
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NPI Number | 1891629051
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Entity Type | Organization
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Legal Business Name | DBA WILD ROOTS THERAPY
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Dates
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Enumeration Date | 06/11/2026
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Last Update Date | 06/11/2026
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Provider Practice Location Address
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Address Line | 1512 S 1100 E STE B
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City | SALT LAKE CITY
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State | UT
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Zip | 84105-2493
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Country | US
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Telephone | 801-231-0946
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Fax |
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Provider Business Mailing Address
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Address Line | 1512 S 1100 E STE B
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City | SALT LAKE CITY
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State | UT
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Zip | 84105-2493
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Country | US
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Telephone | 801-231-0946
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARTHA KATALIN WYLD
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Credential | CMHC
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Telephone | 801-231-0946
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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