Healthcare Provider Details

I. General information

NPI: 1114379336
Provider Name (Legal Business Name): ALEXANDRA WYSS L.A.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST 100
BLOOMINGTON MN
55420-1400
US

IV. Provider business mailing address

1900 SILVER LAKE ROAD NW SUITE 110
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 952-854-5034
  • Fax:
Mailing address:
  • Phone: 651-379-1718
  • Fax: 651-379-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304297
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: