Provider Demographics
NPI:1679176937
Name:WANDERING COLLECTIVE LLC
Entity Type:Organization
Organization Name:WANDERING COLLECTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-895-6416
Mailing Address - Street 1:2514 AMELIA EARHART AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-4003
Mailing Address - Country:US
Mailing Address - Phone:404-895-6416
Mailing Address - Fax:
Practice Address - Street 1:5960 S LAND PARK DR # 1194
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-3313
Practice Address - Country:US
Practice Address - Phone:404-895-6416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty