Healthcare Provider Details

I. General information

NPI: 1619869070
Provider Name (Legal Business Name): WILD ROSE HEART LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 GRANT ST
LONGMONT CO
80501-3710
US

IV. Provider business mailing address

1200 GRANT ST
LONGMONT CO
80501-3710
US

V. Phone/Fax

Practice location:
  • Phone: 970-402-2246
  • Fax:
Mailing address:
  • Phone: 970-402-2246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIARA DEL ROSARIO RAFAEL
Title or Position: LEAD SOMATIC THERAPIST
Credential: B.S, M.A, LPCC
Phone: 970-402-2246