Healthcare Provider Details

I. General information

NPI: 1518769421
Provider Name (Legal Business Name): LITTLE WILDFLOWER PLAY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 6TH AVE
BROOKINGS SD
57006-1431
US

IV. Provider business mailing address

630 6TH AVE
BROOKINGS SD
57006-1431
US

V. Phone/Fax

Practice location:
  • Phone: 605-491-4799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BROOKE RUSTMAN
Title or Position: OWNER, CLINICIAN
Credential: LPC, RPT
Phone: 605-491-4799