Healthcare Provider Details

I. General information

NPI: 1255066163
Provider Name (Legal Business Name): BORN TO BLOSSOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2022
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 MILITARY AVE
BAXTER SPRINGS KS
66713-1509
US

IV. Provider business mailing address

1141 MILITARY AVE
BAXTER SPRINGS KS
66713-1509
US

V. Phone/Fax

Practice location:
  • Phone: 620-330-9036
  • Fax: 620-206-2514
Mailing address:
  • Phone: 620-330-9036
  • Fax: 620-206-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALEXANDRIA WILBERT
Title or Position: OWNER/CEO
Credential: BCBA, LBA, LMLP
Phone: 417-540-7259