Provider Demographics
NPI:1073365656
Name:WILD MINDS THERAPY, LLC
Entity Type:Organization
Organization Name:WILD MINDS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-377-3644
Mailing Address - Street 1:4401 FORGE RD
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9504
Mailing Address - Country:US
Mailing Address - Phone:443-377-3644
Mailing Address - Fax:
Practice Address - Street 1:4401 FORGE RD
Practice Address - Street 2:
Practice Address - City:PERRY HALL
Practice Address - State:MD
Practice Address - Zip Code:21128-9504
Practice Address - Country:US
Practice Address - Phone:443-377-3644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health