Provider Demographics
NPI:1851102123
Name:WILD WILLOW THERAPY LLC
Entity type:Organization
Organization Name:WILD WILLOW THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCER WETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:307-381-6400
Mailing Address - Street 1:1022 DIVIDE ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1022 DIVIDE ST
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4813
Practice Address - Country:US
Practice Address - Phone:307-381-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356716930OtherNPI