MEDICARE: WILD HEART THERAPY 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1912718883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD HEART THERAPY PLLC

Provider Business Mailing Address
First Line	:	4537 N LEAVITT ST APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1673
Country	:	US
Telephone Number	:	574-276-5018
Fax Number	:

Provider Business Practice Location Address
First Line	:	4537 N LEAVITT ST APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1673
Country	:	US
Telephone Number	:	574-276-5018
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MARY KATHLEEN REAGAN
Credential	:	LLC
Telephone Number	:	574-276-5018

Provider Enumeration Date	:	01/18/2025
Last Update Date	:	01/18/2025

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