Provider Demographics
NPI:1104636968
Name:WILD HERON PLLC
Entity type:Organization
Organization Name:WILD HERON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:KATE
Authorized Official - Last Name:WICKS-ARSHACK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-664-6582
Mailing Address - Street 1:38169 US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-8730
Mailing Address - Country:US
Mailing Address - Phone:917-664-6582
Mailing Address - Fax:
Practice Address - Street 1:38169 US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-8730
Practice Address - Country:US
Practice Address - Phone:917-664-6582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)