Organization
WILD ROOTS COUNSELING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAMAICA SANTOS MOULTON LPC (OWNER)
(307) 254-5048
Entity
Organization
Contact information
Practice address
337 ROBERT ST, CODY, WY 82414-9268
(307) 899-2492
Mailing address
PO BOX 2772, CODY, WY 82414-2772
(307) 899-2492
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
101YP2500X
Professional Counselor
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1326474156
—
WY
Enumeration date
02/27/2023
Last updated
05/28/2024
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