Healthcare Provider Details

I. General information

NPI: 1235668427
Provider Name (Legal Business Name): HOLLIS WUNDERLICH LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 CENTRAL AVE N
FARIBAULT MN
55021
US

IV. Provider business mailing address

PO BOX 431
FARIBAULT MN
55021-0431
US

V. Phone/Fax

Practice location:
  • Phone: 507-491-4848
  • Fax: 507-323-8141
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberCC01537
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01537
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: