Organization
WILD GOOSE COUNSELING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LYDIA ANNA DAVIS LPC. MAC (CO-OWNER)
(907) 953-9614
Entity
Organization
Contact information
Practice address
198 W MARYDALE AVE, SOLDOTNA, AK 99669-7501
(907) 953-9614
Mailing address
379 W KATMAI AVE, SOLDOTNA, AK 99669-7315
(907) 953-9614
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
AK
261QM0850X
Adult Mental Health Clinic/Center
—
AK
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
109622
LICENSED PROFESSIONAL COUNSELOR LYDIA DAVIS
AK
01
—
109623
LICENSED PROFESSIONAL COUNSELOR MOLLY DAVIS
AK
Enumeration date
06/05/2017
Last updated
06/05/2017
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