Provider Demographics
NPI:1740061969
Name:WILDERNESS THERAPY LLC
Entity type:Organization
Organization Name:WILDERNESS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-905-6795
Mailing Address - Street 1:539 POTOMAC RD
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-4825
Mailing Address - Country:US
Mailing Address - Phone:443-905-6795
Mailing Address - Fax:
Practice Address - Street 1:5900 YORK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3041
Practice Address - Country:US
Practice Address - Phone:443-905-6795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health