Basic Information
| Provider Information | |||||||||
| NPI: | 1083689624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANDERSEE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MSW LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 34TH AVE S | ||||||||
| Address2: | 21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528835790 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 11475 ROBINSON DR NW | ||||||||
| Address2: | MAIL STOP 32600A | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554333746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637544600 | ||||||||
| FaxNumber: | 7637544614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| 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 | 1041C0700X | 01593 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.