Provider Demographics
NPI:1124856869
Name:WILDERHEART THERAPY LLC
Entity type:Organization
Organization Name:WILDERHEART THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WERNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC
Authorized Official - Phone:407-717-8245
Mailing Address - Street 1:7532 AZUREBROOK CT
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8702
Mailing Address - Country:US
Mailing Address - Phone:407-717-8245
Mailing Address - Fax:
Practice Address - Street 1:7532 AZUREBROOK CT
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8702
Practice Address - Country:US
Practice Address - Phone:407-717-8245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty