Healthcare Provider Details

I. General information

NPI: 1881078145
Provider Name (Legal Business Name): WANDA J DAHLEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WANDA J MCSPARRON PH.D.

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 8TH ST SE
DETROIT LAKES MN
56501-2839
US

IV. Provider business mailing address

928 8TH ST SE
DETROIT LAKES MN
56501-2839
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-1676
  • Fax:
Mailing address:
  • Phone: 218-847-1676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP4577
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: