Provider Demographics
NPI:1225541170
Name:WILDSTONE WELLNESS, LLC
Entity Type:Organization
Organization Name:WILDSTONE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-424-6624
Mailing Address - Street 1:189 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2901
Mailing Address - Country:US
Mailing Address - Phone:262-424-6624
Mailing Address - Fax:
Practice Address - Street 1:14135 N CEDARBURG RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-1416
Practice Address - Country:US
Practice Address - Phone:262-424-6624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7870-123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health