Tomas John Wildenborg, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

25741 Issued in MN

Practice address

2400 W 64TH St
Minneapolis, MN 55423-1001

Phone

(612) 861-1688

NPI assigned

Nov 15, 2011

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 2013

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Fraser Child and Family CenterGroup PAC ID 3971918772, 54 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Fraser Child and Family Center

  • Adolescent and Children Mental Health Clinic/Center
  • Minneapolis, MN
  • NPI 1609922194
  Medicare reassignment Care Compare group NPD
• Fraser

  • Rehabilitation Clinic/Center
  • Richfield, MN
  • NPI 1063568574
  NPD (past)
• Cascadia Behavioral Health

  • Adult Companion
  • Portland, OR
  • NPI 1083751663
  NPD (past)
• Cascadia Health

  dba Cascadia Behavioral Healthcare, Inc.

  • Multi-Specialty Clinic/Center
  • Portland, OR
  • NPI 1669541058
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1321315200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1618444800000",
    "number": "1023395282",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2400 W 64TH ST",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554231001",
            "telephone_number": "612-861-1688"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2400 W 64TH ST",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554231001",
            "telephone_number": "612-861-1688"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILDENBORG",
        "first_name": "TOMAS",
        "middle_name": "JOHN",
        "credential": "LICSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-11-15",
        "last_updated": "2021-04-15",
        "certification_date": "2021-04-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "25741",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kristin Wilcox, MS, LPCC, LADC
• Erica Wilczek, PT, DPT
• Wild Hope Psychological Services LLC
• Anne Wild, LGSW
• Mark J Wilde, MA, LMFT
• Denise Wilder, M.EQ.
• Sanaa Tiairr Wilder
• Tira Marie Wiley-Walker
• Lyn Marie Wiley, COMS
• Kieona Naomie Wilford, DOULA

• Clinical Social Worker in Minneapolis, MN
• Providers in Minneapolis, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.