1083689624 NPI number — RICHARD ALAN WANDERSEE MSW LICSW

Table of content: RICHARD ALAN WANDERSEE MSW LICSW (NPI 1083689624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083689624 NPI number — RICHARD ALAN WANDERSEE MSW LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANDERSEE
Provider First Name:
RICHARD
Provider Middle Name:
ALAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW LICSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083689624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8100 34TH AVE S
Provider Second Line Business Mailing Address:
21110Q
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-5790
Provider Business Mailing Address Fax Number:
952-883-5395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11475 ROBINSON DR NW
Provider Second Line Business Practice Location Address:
MAIL STOP 32600A
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-3746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-754-4600
Provider Business Practice Location Address Fax Number:
763-754-4614
Provider Enumeration Date:
02/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  01593 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com