Provider Demographics
NPI:1811613599
Name:WILDWOOD MENTAL HEALTH LLC
Entity type:Organization
Organization Name:WILDWOOD MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPCC
Authorized Official - Prefix:
Authorized Official - First Name:TABBATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITCHKE HERDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-301-6278
Mailing Address - Street 1:204 NW 1ST AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 NW 1ST AVE STE 4
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2749
Practice Address - Country:US
Practice Address - Phone:218-301-6278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty