Basic Information
| Provider Information | |||||||||
| NPI: | 1841442209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANNER-PERRY | ||||||||
| FirstName: | DENA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D., LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WANNER | ||||||||
| OtherFirstName: | DENA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 4TH AVE W | ||||||||
| Address2: | |||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553791220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524968565 | ||||||||
| FaxNumber: | 9524968430 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 W 66TH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726999 | ||||||||
| FaxNumber: | 6126722691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2008 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP5133 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | LP575P | ND | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1841442209 | 05 | MN | MEDICAID |