Provider Demographics
NPI:1659930519
Name:WILDFLOWER COUNSELING LLC
Entity Type:Organization
Organization Name:WILDFLOWER COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:LEE (HAYLEY)
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MS LMFT
Authorized Official - Phone:608-531-4143
Mailing Address - Street 1:2961 YARMOUTH GREENWAY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5809
Mailing Address - Country:US
Mailing Address - Phone:608-571-4143
Mailing Address - Fax:608-531-2790
Practice Address - Street 1:2961 YARMOUTH GREENWAY DR STE 2
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5809
Practice Address - Country:US
Practice Address - Phone:608-571-4143
Practice Address - Fax:608-531-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health