Provider Demographics
NPI:1295460566
Name:WILD WILLOW COUNSELING, PLLC
Entity Type:Organization
Organization Name:WILD WILLOW COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LAMFT
Authorized Official - Phone:623-777-9696
Mailing Address - Street 1:4625 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7127
Mailing Address - Country:US
Mailing Address - Phone:623-777-9696
Mailing Address - Fax:
Practice Address - Street 1:4625 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7127
Practice Address - Country:US
Practice Address - Phone:623-777-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty