Provider Demographics
NPI:1487355020
Name:WILDFLOWER THERAPY SERVICES
Entity type:Organization
Organization Name:WILDFLOWER THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-200-1215
Mailing Address - Street 1:13750 CROSSTOWN DR NW STE 102
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5855
Mailing Address - Country:US
Mailing Address - Phone:763-200-1215
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR NW STE 102
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5855
Practice Address - Country:US
Practice Address - Phone:763-200-1215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-10
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty