Provider Demographics
NPI:1114579877
Name:WILD MOON INTEGRATIVE THERAPIES: CYCLE-CENTERED HEALING
Entity Type:Organization
Organization Name:WILD MOON INTEGRATIVE THERAPIES: CYCLE-CENTERED HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ST.CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, R-DMT, RYT
Authorized Official - Phone:718-974-6645
Mailing Address - Street 1:6101 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5146
Mailing Address - Country:US
Mailing Address - Phone:718-974-6645
Mailing Address - Fax:
Practice Address - Street 1:6101 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5146
Practice Address - Country:US
Practice Address - Phone:718-974-6645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty