Provider Demographics
NPI:1043514169
Name:WILSON, STEVEN RODNEY (LP)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:RODNEY
Last Name:WILSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20425 SUMMERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-9228
Mailing Address - Country:US
Mailing Address - Phone:952-451-7003
Mailing Address - Fax:
Practice Address - Street 1:20425 SUMMERVILLE RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-9228
Practice Address - Country:US
Practice Address - Phone:952-451-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5164103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist