=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912718883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILD HEART THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2025
-----------------------------------------------------
Last Update Date | 01/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4537 N LEAVITT ST APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-276-5018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4537 N LEAVITT ST APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-276-5018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MARY KATHLEEN REAGAN
-----------------------------------------------------
Credential | LLC
-----------------------------------------------------
Telephone | 574-276-5018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------