Healthcare Provider Details

I. General information

NPI: 1972445997
Provider Name (Legal Business Name): DEEP LAKE COUNSELING SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15611 YAKIMA ST NW
RAMSEY MN
55303-4262
US

IV. Provider business mailing address

15611 YAKIMA ST NW
RAMSEY MN
55303-4262
US

V. Phone/Fax

Practice location:
  • Phone: 763-233-2870
  • Fax:
Mailing address:
  • Phone: 763-233-2870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: BRIAN THOMAS WILTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LPCC, LADC
Phone: 763-233-2870