Basic Information
| Provider Information | |||||||||
| NPI: | 1962423202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONDERLICH | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 4TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344111 | ||||||||
| FaxNumber: | 7012344130 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 4TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344111 | ||||||||
| FaxNumber: | 7012344130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 11/10/2008 | ||||||||
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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 | 103TP0814X | 187 | ND | Y | Behavioral Health & Social Service Providers | Psychologist | Psychoanalysis |
ID Information
| ID | Type | State | Issuer | Description | 16965 | 05 | ND | MEDICAID | 014550500 | 05 | MN | MEDICAID |