Provider Demographics
NPI:1942429667
Name:RODREICK WILSON, KRISTIN B (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:B
Last Name:RODREICK WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1528
Mailing Address - Country:US
Mailing Address - Phone:952-484-8015
Mailing Address - Fax:
Practice Address - Street 1:6401 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical