Healthcare Provider Details

I. General information

NPI: 1487384806
Provider Name (Legal Business Name): WYATT HAUGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date: 10/03/2022
Reactivation Date: 10/08/2025

III. Provider practice location address

920 10TH ST
CLARKFIELD MN
56223-1377
US

IV. Provider business mailing address

PO BOX 189
MONTEVIDEO MN
56265-0189
US

V. Phone/Fax

Practice location:
  • Phone: 320-321-2239
  • Fax:
Mailing address:
  • Phone: 320-321-2239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: