Provider Demographics
NPI:1225662760
Name:WILSON, DANIELLE RAE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:RAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19499 SILVER FOX DR
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-5041
Mailing Address - Country:US
Mailing Address - Phone:651-354-3057
Mailing Address - Fax:
Practice Address - Street 1:72351 PINE RIVER RD
Practice Address - Street 2:
Practice Address - City:WILLOW RIVER
Practice Address - State:MN
Practice Address - Zip Code:55795-3120
Practice Address - Country:US
Practice Address - Phone:218-372-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN259811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN25981Medicaid