Provider Demographics
NPI:1245029792
Name:WILD EXPANSE COUNSELING PLLC
Entity type:Organization
Organization Name:WILD EXPANSE COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIOLET
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-828-2693
Mailing Address - Street 1:1074 1/2 E KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2404
Mailing Address - Country:US
Mailing Address - Phone:603-828-2693
Mailing Address - Fax:
Practice Address - Street 1:1518 S 1100 E STE B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2579
Practice Address - Country:US
Practice Address - Phone:385-355-4478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health