=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922914415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILDFLOWER WELLNESS THERAPY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2026
-----------------------------------------------------
Last Update Date | 08/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 622 BERRY RD
-----------------------------------------------------
City | HOWARD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43028-9542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-263-7231
-----------------------------------------------------
Fax | 844-870-0403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 622 BERRY RD
-----------------------------------------------------
City | HOWARD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43028-9542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-263-7231
-----------------------------------------------------
Fax | 844-870-0403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER, CFO, COO
-----------------------------------------------------
Name | MRS. STACEY ROSSELOT
-----------------------------------------------------
Credential | OTD, MOTR/L
-----------------------------------------------------
Telephone | 740-263-7231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------