Wild Magnolia Wellness
Organization Active NPI Community/Behavioral Health Agency · Los Ranchos, NM
NPI 1255820205 · NPPES record last updated Jul 1, 2026
Key facts
- NPI
- 1255820205
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Behavioral Health Agency 251S00000X
- License
- 0139371 (NM)
- Legal business name
- WILD MAGNOLIA WELLNESS
- Practice address
- 6501 4TH St NW Ste H-5
Los Ranchos, NM 87107-5800 - Phone
- (505) 274-0112
- NPI assigned
- May 4, 2018
- Organization subpart
- No
Authorized official
- Name
- Ashley Susan McKenna, LPCC
- Title
- Owner
- Phone
- (505) 274-0112
Practitioners 13
-
Ashley Susan McKenna, LPCC
-
Andrea Busich, LCSW
-
Hayley Hathaway, LMSW
-
Margaret McIntyre Matteucci, MA, NCC, LMHC, CCISM
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NM
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210121001173 | NM | Part B Supplier - Clinic/Group Practice | 8729492491 |
Receives reassigned benefits from 7 practitioners Practice locations: Los Ranchos, NM; Albuquerque, NM |
National Provider Directory
Locations
6501 4th St NW
Ste H5
Los Ranchos, NM 87107
Phone (505) 274-0112
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Behavioral Health Agency | 251S00000X | 0139371 | NM | Yes |
Addresses
Primary practice location
6501 4TH St NW Ste H-5
Los Ranchos, NM 87107-5800
Mailing address
4304 Carlisle Blvd NE
Albuquerque, NM 87107-4811
Phone (505) 274-0112
Other practice location 1
4304 Carlisle Blvd NE
Albuquerque, NM 87107-4811
Phone (505) 433-7561
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 69256357 | Medicaid | NM |
NPI Registry JSON
{
"created_epoch": "1525392000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1782864000000",
"number": "1255820205",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4304 CARLISLE BLVD NE",
"city": "ALBUQUERQUE",
"state": "NM",
"postal_code": "871074811",
"telephone_number": "505-274-0112"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6501 4TH ST NW STE H-5",
"city": "LOS RANCHOS",
"state": "NM",
"postal_code": "871075800",
"telephone_number": "505-274-0112"
}
],
"practiceLocations": [
{
"address_1": "4304 Carlisle Blvd NE",
"address_purpose": "LOCATION",
"city": "Albuquerque",
"state": "NM",
"postal_code": "871074811",
"country_code": "US",
"telephone_number": "505-433-7561",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"organization_name": "WILD MAGNOLIA WELLNESS",
"organizational_subpart": "NO",
"enumeration_date": "2018-05-04",
"last_updated": "2026-07-01",
"certification_date": "2026-07-01",
"status": "A",
"authorized_official_last_name": "MCKENNA",
"authorized_official_first_name": "ASHLEY",
"authorized_official_middle_name": "SUSAN",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "505-274-0112",
"authorized_official_credential": "LPCC"
},
"taxonomies": [
{
"code": "251S00000X",
"taxonomy_group": "",
"desc": "Community/Behavioral Health",
"state": "NM",
"license": "0139371",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "69256357",
"state": "NM"
}
],
"endpoints": [],
"other_names": []
}Other providers in Los Ranchos, NM
- Walgreen Co
- Dominic Weiler
- Benjamin Thomas White
- Martha White
- Kristen S. Wiese
- Laura Ross Wood
- Mary Jane Zimmerman
All providers in Los Ranchos, NM · Community/Behavioral Health Agency in New Mexico
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 1, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.