Provider Demographics
NPI:1689295693
Name:WILD: WOMEN AND INFANTS LONG-TERM DEVELOPMENT, LLC
Entity Type:Organization
Organization Name:WILD: WOMEN AND INFANTS LONG-TERM DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRZASTOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:812-219-0743
Mailing Address - Street 1:515 WEEDON ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5640
Mailing Address - Country:US
Mailing Address - Phone:812-219-0743
Mailing Address - Fax:
Practice Address - Street 1:1003 MAHONE ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6214
Practice Address - Country:US
Practice Address - Phone:540-693-0274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine