Healthcare Provider Details

I. General information

NPI: 1720992076
Provider Name (Legal Business Name): EVERWILD THERAPY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1896 COUNTY HWY NN
WEST BEND WI
53095-9712
US

IV. Provider business mailing address

2601 ELKHART DR APT 319
WAUKESHA WI
53189-8820
US

V. Phone/Fax

Practice location:
  • Phone: 414-688-8888
  • Fax:
Mailing address:
  • Phone: 262-208-5087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICOLE BALISTRERI
Title or Position: CO-FOUNDER/OCCUPATIONAL THERAPIST
Credential: MS, OT
Phone: 262-208-5087