Provider Demographics
NPI:1053086793
Name:WILDLY AUTHENTIC COUNSELING, LLC
Entity Type:Organization
Organization Name:WILDLY AUTHENTIC COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:SCHAET
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LPC
Authorized Official - Phone:904-885-8278
Mailing Address - Street 1:175 SE APACHE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1723
Mailing Address - Country:US
Mailing Address - Phone:904-885-8278
Mailing Address - Fax:
Practice Address - Street 1:12443 SAN JOSE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8648
Practice Address - Country:US
Practice Address - Phone:904-337-9040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty