Healthcare Provider Details

I. General information

NPI: 1922918176
Provider Name (Legal Business Name): WILDFORM THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 8TH ST STE 880
PUEBLO CO
81003-3037
US

IV. Provider business mailing address

201 W 8TH ST STE 880
PUEBLO CO
81003-3037
US

V. Phone/Fax

Practice location:
  • Phone: 719-215-8347
  • Fax:
Mailing address:
  • Phone: 719-215-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. KURTIS JAMES RIVERA
Title or Position: CEO
Credential: MAFP, MA, LPC, CAS
Phone: 719-215-8347