Healthcare Provider Details

I. General information

NPI: 1952750788
Provider Name (Legal Business Name): DAVID ALAN WHEELHOUSE LADC, CPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 QUANTRELLE AVE NE
OTSEGO MN
55330-0168
US

IV. Provider business mailing address

1900 SILVER LAKE ROAD NW SUITE 110
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-9492
  • Fax: 763-746-3685
Mailing address:
  • Phone: 651-379-1718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304499
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: