Basic Information
| Provider Information | |||||||||
| NPI: | 1225541170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILDSTONE WELLNESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | CEDARBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530122901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624246624 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624246624 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2017 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | HALE | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, PSYCHOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2624246624 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 7870-123 | WI | Y | Agencies | Community/Behavioral Health |
No ID Information.