Healthcare Provider Details

I. General information

NPI: 1245029792
Provider Name (Legal Business Name): WILD EXPANSE COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 S 1100 E STE B
SALT LAKE CITY UT
84105-2579
US

IV. Provider business mailing address

1074 1/2 E KENSINGTON AVE
SALT LAKE CITY UT
84105-2404
US

V. Phone/Fax

Practice location:
  • Phone: 385-355-4478
  • Fax:
Mailing address:
  • Phone: 603-828-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VIOLET FLOROS
Title or Position: OWNER
Credential:
Phone: 603-828-2693