Provider Demographics
NPI:1376046425
Name:WILDLY CURATIVE
Entity Type:Organization
Organization Name:WILDLY CURATIVE
Other - Org Name:WILDLY CURATIVE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP, NCC, CCMHC
Authorized Official - Phone:931-319-5348
Mailing Address - Street 1:11145 PETE CARR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER POINT
Mailing Address - State:TN
Mailing Address - Zip Code:38582-6278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:TN
Practice Address - Zip Code:38544-5280
Practice Address - Country:US
Practice Address - Phone:931-588-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty