Provider Demographics
NPI:1245443662
Name:WISDOM TRADITIONS WELLNESS, LLC
Entity type:Organization
Organization Name:WISDOM TRADITIONS WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:PT,LAC,MHS,DIPLAC
Authorized Official - Phone:907-644-0722
Mailing Address - Street 1:615 E 82ND AVENUE SUITE B-5
Mailing Address - Street 2:SUITE #17
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518
Mailing Address - Country:US
Mailing Address - Phone:907-644-0722
Mailing Address - Fax:888-957-1346
Practice Address - Street 1:615 E 82ND AVENUE SUITE B-5
Practice Address - Street 2:SUITE #17
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518
Practice Address - Country:US
Practice Address - Phone:907-644-0722
Practice Address - Fax:888-957-1346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK88171100000X
AK1612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty