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General NPI Number Information
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NPI Number | 1972449718
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Entity Type | Organization
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Legal Business Name | WILD PEACE INTEGRATIVE WELLNESS PLLC
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Dates
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Enumeration Date | 04/24/2026
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Last Update Date | 04/24/2026
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Provider Practice Location Address
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Address Line | 2378 WILSHIRE BLVD
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City | MOUND
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State | MN
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Zip | 55364-1652
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Country | US
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Telephone | 570-903-1133
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Fax |
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Provider Business Mailing Address
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Address Line | 5687 MAIN ST W
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City | MAPLE PLAIN
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State | MN
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Zip | 55359-9533
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Country | US
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Telephone | 570-903-1133
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Fax |
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Authorized Official
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Title or Position | ORGANIZER
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Name | KEELY HEISER
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Credential | LICSW
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Telephone | 570-903-1133
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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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