Basic Information
| Provider Information | |||||||||
| NPI: | 1225453426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALES | ||||||||
| FirstName: | WALTER | ||||||||
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| Credential: | LICSW, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 614 MICHIGAN AVE W | ||||||||
| Address2: | |||||||||
| City: | WALKER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564842276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185477700 | ||||||||
| FaxNumber: | 2185477729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2014 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 303896 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 23322 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.