Healthcare Provider Details

I. General information

NPI: 1235797853
Provider Name (Legal Business Name): WILD MEADOWS COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 CHERRY HILL ALCOVE
HAMEL MN
55340-9333
US

IV. Provider business mailing address

239 CHERRY HILL ALCOVE
HAMEL MN
55340-9333
US

V. Phone/Fax

Practice location:
  • Phone: 715-541-2424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN TRESNESS
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 715-541-2424