Provider Demographics
NPI:1811554470
Name:WILD BLOOMS THERAPY LLC
Entity Type:Organization
Organization Name:WILD BLOOMS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NAUSHEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-709-4259
Mailing Address - Street 1:5840 N CANTON CENTER RD STE 282
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2614
Mailing Address - Country:US
Mailing Address - Phone:734-905-0940
Mailing Address - Fax:734-357-0766
Practice Address - Street 1:5840 N CANTON CENTER RD STE 282
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2614
Practice Address - Country:US
Practice Address - Phone:734-905-0940
Practice Address - Fax:734-357-0766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty