Provider Demographics
NPI:1285915199
Name:WILD IRISH FARM, LLC
Entity type:Organization
Organization Name:WILD IRISH FARM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:603-436-2022
Mailing Address - Street 1:408 NEWINGTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2730
Mailing Address - Country:US
Mailing Address - Phone:603-436-2022
Mailing Address - Fax:
Practice Address - Street 1:408 NEWINGTON RD
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:NH
Practice Address - Zip Code:03801-2730
Practice Address - Country:US
Practice Address - Phone:603-436-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty