Provider Demographics
NPI:1578267290
Name:WILDFLOWER COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:WILDFLOWER COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:N
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:630-687-0032
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074-0334
Mailing Address - Country:US
Mailing Address - Phone:269-224-2339
Mailing Address - Fax:
Practice Address - Street 1:4000 PORTAGE ST STE 107
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-4962
Practice Address - Country:US
Practice Address - Phone:269-224-2339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty