Healthcare Provider Details

I. General information

NPI: 1104720655
Provider Name (Legal Business Name): TODDIE JAMES WILSON I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50450 WATERS EDGE DR
DEER RIVER MN
56636-2889
US

IV. Provider business mailing address

50450 WATERS EDGE DR
DEER RIVER MN
56636-2889
US

V. Phone/Fax

Practice location:
  • Phone: 218-368-1779
  • Fax: 218-335-7294
Mailing address:
  • Phone: 218-368-1779
  • Fax: 218-335-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12-0258-MA
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: