Provider Demographics
NPI:1437965100
Name:WILD MIND THERAPY PLLC
Entity type:Organization
Organization Name:WILD MIND THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRAZIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-727-8803
Mailing Address - Street 1:4662 IDE RD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NY
Mailing Address - Zip Code:14172-9758
Mailing Address - Country:US
Mailing Address - Phone:716-727-8803
Mailing Address - Fax:
Practice Address - Street 1:4648 IDE RD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NY
Practice Address - Zip Code:14172-9758
Practice Address - Country:US
Practice Address - Phone:716-727-8803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty