Healthcare Provider Details

I. General information

NPI: 1841956067
Provider Name (Legal Business Name): WILDERNESS BLOOMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MAIN ST
VAN BUREN AR
72956-4731
US

IV. Provider business mailing address

PO BOX 655
FAYETTEVILLE AR
72702-0655
US

V. Phone/Fax

Practice location:
  • Phone: 479-352-3128
  • Fax:
Mailing address:
  • Phone: 479-222-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. KRISTIN LEE TEMPLE
Title or Position: OWNER
Credential: LPC
Phone: 479-222-0017