MEDICARE: WILD RECOVERY LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1780485854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD RECOVERY LLC

Provider Business Mailing Address
First Line	:	10464 HOLLYWOOD BLVD NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-4517
Country	:	US
Telephone Number	:	612-201-2280
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 MOORE LAKE DR E STE 200
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5136
Country	:	US
Telephone Number	:	612-201-2280
Fax Number	:

Authorized Official
Title or Position	:	CEO/LPCC/LADC
Name	:	TRACY LEE ALVIN DOERR
Credential	:	LPCC, LADC
Telephone Number	:	612-201-2280

Provider Enumeration Date	:	03/24/2025
Last Update Date	:	01/13/2026

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Directions to “WILD RECOVERY LLC ” Practice Location

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