MEDICARE: DR. KRISTIN ALYSE WIGGS PHD, LP

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	103T00000X	Psychologist	LP6169	MN

General Provider Information

NPI Number	:	1679092803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTIN ALYSE WIGGS PHD, LP

Provider Business Mailing Address
First Line	:	2833 LYNDALE AVE S APT 225
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2977
Country	:	US
Telephone Number	:	847-280-0095
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 S 8TH ST STE 600
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-1209
Country	:	US
Telephone Number	:	612-873-9494
Fax Number	:

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

Provider Enumeration Date	:	09/19/2017
Last Update Date	:	10/20/2017

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