Provider Demographics
NPI:1194140467
Name:WILDWOOD, SONJA (LPCC)
Entity type:Individual
Prefix:
First Name:SONJA
Middle Name:
Last Name:WILDWOOD
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 ALLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-1562
Mailing Address - Country:US
Mailing Address - Phone:612-462-8226
Mailing Address - Fax:
Practice Address - Street 1:4321 ALLENDALE AVE
Practice Address - Street 2:DULUTH
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-1562
Practice Address - Country:US
Practice Address - Phone:218-728-7500
Practice Address - Fax:218-728-7501
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MNCC01246101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health