Provider Demographics
NPI:1205537651
Name:EMBODIED WILD INTEGRATIVE COUNSELING
Entity type:Organization
Organization Name:EMBODIED WILD INTEGRATIVE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VISTE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PCLC
Authorized Official - Phone:406-404-6629
Mailing Address - Street 1:PO BOX 17951
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-7951
Mailing Address - Country:US
Mailing Address - Phone:406-404-6629
Mailing Address - Fax:
Practice Address - Street 1:415 N HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4557
Practice Address - Country:US
Practice Address - Phone:406-404-6629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty