Healthcare Provider Details

I. General information

NPI: 1992619910
Provider Name (Legal Business Name): WILDLIGHT THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16360 E BAILS PL
AURORA CO
80017-5129
US

IV. Provider business mailing address

16360 E BAILS PL
AURORA CO
80017-5129
US

V. Phone/Fax

Practice location:
  • Phone: 574-514-8067
  • Fax:
Mailing address:
  • Phone: 574-514-8067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIERA PELLETIER
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: MA, LPC
Phone: 574-514-8067