Organization
WILD MAGNOLIA WELLNESS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ASHLEY SUSAN MCKENNA LPCC (OWNER)
(505) 274-0112
Entity
Organization
Contact information
Practice address
6501 4TH ST NW STE H-5, LOS RANCHOS, NM 87107-5800
(505) 274-0112
Mailing address
4304 CARLISLE BLVD NE, ALBUQUERQUE, NM 87107-4811
(505) 274-0112
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
0139371
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1730112483
—
NM
05
—
69256357
—
NM
Enumeration date
05/04/2018
Last updated
05/04/2026
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