MEDICARE: BEX WILDE

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	106H00000X	Marriage & Family Therapist	4273	MN

General Provider Information

NPI Number	:	1609630458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEX WILDE

Provider Business Mailing Address
First Line	:	2157 GERANIUM AVE E
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55119-3345
Country	:	US
Telephone Number	:	503-949-0400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2157 GERANIUM AVE E
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55119-3345
Country	:	US
Telephone Number	:	503-949-0400
Fax Number	:

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

Provider Enumeration Date	:	02/12/2024
Last Update Date	:	02/12/2024

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Directions to “ BEX WILDE ” Practice Location

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