Healthcare Provider Details

I. General information

NPI: 1558278556
Provider Name (Legal Business Name): WILDFOLK COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 NE REVERE AVE
BEND OR
97701-4161
US

IV. Provider business mailing address

4006 FORESTDALE DR
PARK CITY UT
84098-5949
US

V. Phone/Fax

Practice location:
  • Phone: 801-613-2120
  • Fax:
Mailing address:
  • Phone: 810-613-2130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LINDSEY BOONE
Title or Position: PRESIDENT
Credential:
Phone: 801-613-2120