Provider Demographics
NPI:1700651650
Name:WILDWOODS COUNSELING LLC
Entity type:Organization
Organization Name:WILDWOODS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/ WILDWOODS COUNSELING
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BLAZINA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-975-7723
Mailing Address - Street 1:54 SKYLINE DR # USA
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-9306
Mailing Address - Country:US
Mailing Address - Phone:505-975-7723
Mailing Address - Fax:
Practice Address - Street 1:54 SKYLINE DR # USA
Practice Address - Street 2:
Practice Address - City:SANDIA PARK
Practice Address - State:NM
Practice Address - Zip Code:87047-9306
Practice Address - Country:US
Practice Address - Phone:505-975-7723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty