MEDICARE: DENISE WILDER M.EQ.

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	103TC0700X	Clinical Psychologist	LP0867	MN

General Provider Information

NPI Number	:	1700834488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE WILDER M.EQ.

Provider Business Mailing Address
First Line	:	1409 WILLOW ST
Second Line	:	SUITE 300
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2269
Country	:	US
Telephone Number	:	612-870-1242
Fax Number	:	612-870-8077

Provider Business Practice Location Address
First Line	:	1409 WILLOW ST
Second Line	:	SUITE 300
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2269
Country	:	US
Telephone Number	:	612-870-1242
Fax Number	:	612-870-8077

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/08/2007

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