Provider Demographics
NPI:1891224879
Name:WILD GOOSE COUNSELING LLC
Entity type:Organization
Organization Name:WILD GOOSE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:ANNA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC MAC
Authorized Official - Phone:907-953-9614
Mailing Address - Street 1:379 W KATMAI AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7315
Mailing Address - Country:US
Mailing Address - Phone:907-953-9614
Mailing Address - Fax:
Practice Address - Street 1:198 W MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7501
Practice Address - Country:US
Practice Address - Phone:907-953-9614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QM0855X, 261QM0850X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK109623OtherLICENSED PROFESSIONAL COUNSELOR MOLLY DAVIS
AK109622OtherLICENSED PROFESSIONAL COUNSELOR LYDIA DAVIS