Healthcare Provider Details

I. General information

NPI: 1043260110
Provider Name (Legal Business Name): GARY A WALLINGA PHD LP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR SUITE 1325
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-5796
  • Fax: 320-229-5179
Mailing address:
  • Phone: 320-251-2700
  • Fax: 320-656-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP2053
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: