Provider Demographics
NPI:1073928701
Name:THAD WILDERSON & ASSOCIATES PA
Entity Type:Organization
Organization Name:THAD WILDERSON & ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE & FINANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAVES
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:651-225-8997
Mailing Address - Street 1:475 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1959
Mailing Address - Country:US
Mailing Address - Phone:651-225-8997
Mailing Address - Fax:
Practice Address - Street 1:475 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1959
Practice Address - Country:US
Practice Address - Phone:651-225-8997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0061251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health