Provider Demographics
NPI:1538947353
Name:WILDROOTS COLLECTIVE
Entity type:Organization
Organization Name:WILDROOTS COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWBRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:406-212-2456
Mailing Address - Street 1:PO BOX 2829
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:WY
Mailing Address - Zip Code:83128-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:307-333-0843
Practice Address - Street 1:430 B STREET
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:WY
Practice Address - Zip Code:83112-9901
Practice Address - Country:US
Practice Address - Phone:406-212-2456
Practice Address - Fax:307-333-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health