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General NPI Number Information
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NPI Number | 1356406011
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Entity Type | Individual
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Provider Name | ROBERT NICHOLI WILSON PHD
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Gender | Male
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Dates
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Enumeration Date | 12/23/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 403 JACKSON ST SUITE 308
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City | ANOKA
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State | MN
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Zip | 55303-2372
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Country | US
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Telephone | 763-786-9822
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Fax | 763-786-7749
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Provider Business Mailing Address
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Address Line | 403 JACKSON ST SUITE 308
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City | ANOKA
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State | MN
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Zip | 55303-2372
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Country | US
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Telephone | 763-786-9822
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Fax | 763-786-7749
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP-0869
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License Number State | MN
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