Basic Information
| Provider Information | |||||||||
| NPI: | 1790009884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.A., LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8669 EAGLE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELMO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550428628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513790444 | ||||||||
| FaxNumber: | 6513790448 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 MCANDREWS RD W | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528928495 | ||||||||
| FaxNumber: | 6513790448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 2015 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1790009884 | 05 | MN | MEDICAID |