| NPI | 1306973698 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | THAD WILFRED WILDERSON Executive Director 651-225-8997 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent |
| Additional Taxonomies | 251B00000X Case Management (Licence: MN LP0061) |
| Enumeration Date | 2007-02-27 |
| Last Update Date | 2020-08-22 |