MEDICARE: WILD HEARTS RISE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1265067334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD HEARTS RISE

Provider Business Mailing Address
First Line	:	1345 E CHANDLER BLVD STE 107
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-6280
Country	:	US
Telephone Number	:	480-310-0790
Fax Number	:

Provider Business Practice Location Address
First Line	:	1345 E CHANDLER BLVD STE 107
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-6280
Country	:	US
Telephone Number	:	480-310-0790
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	VALERIE SHAND
Credential	:	LCSW
Telephone Number	:	480-310-0790

Provider Enumeration Date	:	03/09/2020
Last Update Date	:	03/09/2020

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Directions to “WILD HEARTS RISE ” Practice Location

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