Healthcare Provider Details

I. General information

NPI: 1932265568
Provider Name (Legal Business Name): RICHARD JOHN WOLLEAT LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W 9TH ST
DULUTH MN
55807-1563
US

IV. Provider business mailing address

2831 E 2ND ST
DULUTH MN
55812-1922
US

V. Phone/Fax

Practice location:
  • Phone: 218-625-2660
  • Fax: 218-628-1347
Mailing address:
  • Phone: 218-724-1994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2569
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: