Provider Demographics
NPI:1407862824
Name:WISHKIDS INTERNATIONAL
Entity Type:Organization
Organization Name:WISHKIDS INTERNATIONAL
Other - Org Name:WISH THERAPEUTIC SERVICES (WTS)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZORODZE
Authorized Official - Suffix:
Authorized Official - Credentials:BEHAVIOR CORDINATOR
Authorized Official - Phone:317-295-9441
Mailing Address - Street 1:4409 EAGLE CREEK PKWY APT 103
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4326
Mailing Address - Country:US
Mailing Address - Phone:317-295-9441
Mailing Address - Fax:317-295-9441
Practice Address - Street 1:754 N SHERMAN DR
Practice Address - Street 2:SUITE 205
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2575
Practice Address - Country:US
Practice Address - Phone:317-295-9441
Practice Address - Fax:317-295-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty