Provider Demographics
NPI:1588436745
Name:WILDFLOWER THERAPY, LLC
Entity type:Organization
Organization Name:WILDFLOWER THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-810-0788
Mailing Address - Street 1:615 S OLIVE PL
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6606
Mailing Address - Country:US
Mailing Address - Phone:801-592-3565
Mailing Address - Fax:
Practice Address - Street 1:1220 N 500 W STE 201
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-1107
Practice Address - Country:US
Practice Address - Phone:385-484-8445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)