Basic Information
| Provider Information | |||||||||
| NPI: | 1689768707 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554335831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637801520 | ||||||||
| FaxNumber: | 7637802114 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550081552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636899407 | ||||||||
| FaxNumber: | 7635520164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP0683 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.