Provider Demographics
NPI:1104673151
Name:WILD ROOTS COUNSELING LLC
Entity type:Organization
Organization Name:WILD ROOTS COUNSELING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-361-7688
Mailing Address - Street 1:11670 FOUNTAINS DR STE 278
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7195
Mailing Address - Country:US
Mailing Address - Phone:612-361-7688
Mailing Address - Fax:612-230-2034
Practice Address - Street 1:11670 FOUNTAINS DR STE 278
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7195
Practice Address - Country:US
Practice Address - Phone:612-361-7688
Practice Address - Fax:612-230-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty