Provider Demographics
NPI:1003647348
Name:WILDROOT COUNSELING
Entity type:Organization
Organization Name:WILDROOT COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:
Authorized Official - First Name:KASSONDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-999-0297
Mailing Address - Street 1:2485 GRANT AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2308
Mailing Address - Country:US
Mailing Address - Phone:801-436-7608
Mailing Address - Fax:
Practice Address - Street 1:2485 GRANT AVE STE 212
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2308
Practice Address - Country:US
Practice Address - Phone:801-436-7608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health