MEDICARE: MARION WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1427862986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARION WILSON

Provider Business Mailing Address
First Line	:	941 HILLWIND RD NE STE 301
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5965
Country	:	US
Telephone Number	:	952-303-5803
Fax Number	:	952-303-4451

Provider Business Practice Location Address
First Line	:	941 HILLWIND RD NE STE 301
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5965
Country	:	US
Telephone Number	:	952-303-5803
Fax Number	:	952-303-4451

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2025
Last Update Date	:	02/05/2025

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