Provider Demographics
NPI:1356195150
Name:INNER WILD THERAPY PLLC
Entity type:Organization
Organization Name:INNER WILD THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-818-5875
Mailing Address - Street 1:3453 W 115TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3622
Mailing Address - Country:US
Mailing Address - Phone:773-818-5875
Mailing Address - Fax:
Practice Address - Street 1:840 W IRVING PARK RD # 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:872-269-4203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health