Healthcare Provider Details

I. General information

NPI: 1710822093
Provider Name (Legal Business Name): AMANDA WILSON ED.S., NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 17TH ST
WINDOM MN
56101-1147
US

IV. Provider business mailing address

1400 17TH ST
WINDOM MN
56101-1147
US

V. Phone/Fax

Practice location:
  • Phone: 507-831-6910
  • Fax:
Mailing address:
  • Phone: 507-831-6910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2040933
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: