Provider Demographics
NPI:1841956067
Name:WILDERNESS BLOOMS
Entity type:Organization
Organization Name:WILDERNESS BLOOMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TEMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LAMFT, MED
Authorized Official - Phone:479-352-3128
Mailing Address - Street 1:300 NW RED BARN CIR APT 212
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-2498
Mailing Address - Country:US
Mailing Address - Phone:479-352-3128
Mailing Address - Fax:
Practice Address - Street 1:1500 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-4731
Practice Address - Country:US
Practice Address - Phone:479-352-3128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty