Provider Demographics
NPI:1700834488
Name:WILDER, DENISE (MEQ)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:MEQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 WILLOW ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2269
Mailing Address - Country:US
Mailing Address - Phone:612-870-1242
Mailing Address - Fax:612-870-8077
Practice Address - Street 1:1409 WILLOW ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2269
Practice Address - Country:US
Practice Address - Phone:612-870-1242
Practice Address - Fax:612-870-8077
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0867103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical