Healthcare Provider Details

I. General information

NPI: 1427913649
Provider Name (Legal Business Name): WILSON RIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1884 MAHOGANY ST
MORA MN
55051-7111
US

IV. Provider business mailing address

7145 375TH AVE NW
DALBO MN
55017-8403
US

V. Phone/Fax

Practice location:
  • Phone: 763-567-3875
  • Fax:
Mailing address:
  • Phone: 763-567-3877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AUTUMN WILSON
Title or Position: CLINICAL COUNSELOR
Credential: LPCC
Phone: 763-567-3875