Provider Demographics
NPI:1316762701
Name:WILD WITHIN WELLNESS LLC
Entity type:Organization
Organization Name:WILD WITHIN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:KATE
Authorized Official - Last Name:HUBBELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:425-299-3097
Mailing Address - Street 1:7 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4401
Mailing Address - Country:US
Mailing Address - Phone:425-299-3097
Mailing Address - Fax:
Practice Address - Street 1:45 NW GREELEY AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2943
Practice Address - Country:US
Practice Address - Phone:425-299-3097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty