MEDICARE: WILDROOTS MENTAL HEALTH & WELLNESS, PLLC

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1871443515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILDROOTS MENTAL HEALTH & WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	1821 WHITE AVE
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2254
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 WHITE AVE
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2254
Country	:	US
Telephone Number	:	313-720-0052
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GINA MARIE DEMATTEO
Credential	:	LLP
Telephone Number	:	313-720-0052

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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