Provider Demographics
NPI:1609630458
Name:WILDE, BEX
Entity Type:Individual
Prefix:
First Name:BEX
Middle Name:
Last Name:WILDE
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 1:2157 GERANIUM AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3345
Mailing Address - Country:US
Mailing Address - Phone:503-949-0400
Mailing Address - Fax:
Practice Address - Street 1:2157 GERANIUM AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-3345
Practice Address - Country:US
Practice Address - Phone:503-949-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4273106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist