Healthcare Provider Details

I. General information

NPI: 1548337355
Provider Name (Legal Business Name): AMHERST H. WILDER FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

IV. Provider business mailing address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

V. Phone/Fax

Practice location:
  • Phone: 651-280-2000
  • Fax: 651-280-2310
Mailing address:
  • Phone: 651-280-2310
  • Fax: 651-280-3995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MORRIS GOODWIN
Title or Position: VICE PRESIDENT ADMINISTRATION
Credential:
Phone: 651-280-2310