Healthcare Provider Details

I. General information

NPI: 1558090738
Provider Name (Legal Business Name): WILDFLOWER EXPRESSIVE ARTS THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 11/07/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAYOVAC DR. SUITE 320
MADISON WI
53711-5371
US

IV. Provider business mailing address

3600 CARNCROSS DR
MCFARLAND WI
53558-9617
US

V. Phone/Fax

Practice location:
  • Phone: 608-520-0846
  • Fax:
Mailing address:
  • Phone: 608-217-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: KELLY J TOLTZIEN
Title or Position: DIRECTOR, OWNER
Credential: LPC, ATR
Phone: 608-520-0846