Basic Information
| Provider Information | |||||||||
| NPI: | 1043260110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLINGA | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PHD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | SUITE 1325 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202555796 | ||||||||
| FaxNumber: | 3202295179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | LP2053 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.