Provider Demographics
NPI:1124902143
Name:WILD IRIS COUNSELING LLC
Entity type:Organization
Organization Name:WILD IRIS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-543-8999
Mailing Address - Street 1:842 E STRATFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1716
Mailing Address - Country:US
Mailing Address - Phone:804-543-8999
Mailing Address - Fax:
Practice Address - Street 1:1518 S 1100 E STE B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2579
Practice Address - Country:US
Practice Address - Phone:385-355-1799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)