Provider Demographics
NPI:1205537693
Name:WILD & WELL RECOVERY LLC
Entity type:Organization
Organization Name:WILD & WELL RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AHQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGY
Authorized Official - Phone:435-669-6669
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:LA VERKIN
Mailing Address - State:UT
Mailing Address - Zip Code:84745-0354
Mailing Address - Country:US
Mailing Address - Phone:435-669-6669
Mailing Address - Fax:
Practice Address - Street 1:211 E CAMPO DESIERTO RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85288-1161
Practice Address - Country:US
Practice Address - Phone:435-669-6669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty