MEDICARE: WILD BLOOM WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1629939392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD BLOOM WELLNESS

Provider Business Mailing Address
First Line	:	11220 TREYNORTH DR STE A
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-8198
Country	:	US
Telephone Number	:	980-272-0157
Fax Number	:

Provider Business Practice Location Address
First Line	:	11220 TREYNORTH DR STE A
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-8198
Country	:	US
Telephone Number	:	980-272-0157
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMIN
Name	:	SUMMER MENDEZ
Credential	:	LCSW
Telephone Number	:	980-272-0157

Provider Enumeration Date	:	11/20/2025
Last Update Date	:	11/20/2025

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Directions to “WILD BLOOM WELLNESS ” Practice Location

Language	Start Address	Practice Location

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