Provider Demographics
NPI:1427750652
Name:WILD LILAC COUNSELING, LLC
Entity type:Organization
Organization Name:WILD LILAC COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-785-5990
Mailing Address - Street 1:8550 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:OLMSTED TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44138-1869
Mailing Address - Country:US
Mailing Address - Phone:440-785-5990
Mailing Address - Fax:
Practice Address - Street 1:24700 CENTER RIDGE RD STE G50
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5671
Practice Address - Country:US
Practice Address - Phone:440-785-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty