Healthcare Provider Details

I. General information

NPI: 1639111834
Provider Name (Legal Business Name): DENISE C. WILSON ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E ALCOTT AVE
FERGUS FALLS MN
56537-2903
US

IV. Provider business mailing address

609 LAKESIDE DRIVE
FERGUS FALLS MN
56537
US

V. Phone/Fax

Practice location:
  • Phone: 218-736-6987
  • Fax: 218-736-6980
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0790
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: