Provider Demographics
NPI:1467227850
Name:WILD ROOTS COUNSELING SERVICES PLLC
Entity Type:Organization
Organization Name:WILD ROOTS COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HERBERHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:970-342-1023
Mailing Address - Street 1:3255 BURNABY DR N
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-8220
Mailing Address - Country:US
Mailing Address - Phone:970-342-1023
Mailing Address - Fax:
Practice Address - Street 1:911 S 9TH ST STE 108
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5858
Practice Address - Country:US
Practice Address - Phone:970-342-1023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health