Provider Demographics
NPI:1710751607
Name:WILDFLOWER MENTAL HEALTH PLLC
Entity Type:Organization
Organization Name:WILDFLOWER MENTAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUBA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:701-699-4052
Mailing Address - Street 1:919 S 7TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5835
Mailing Address - Country:US
Mailing Address - Phone:701-751-1579
Mailing Address - Fax:701-401-0115
Practice Address - Street 1:919 S 7TH ST STE 401
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5835
Practice Address - Country:US
Practice Address - Phone:701-751-1579
Practice Address - Fax:701-401-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-10
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty