Healthcare Provider Details

I. General information

NPI: 1255980512
Provider Name (Legal Business Name): BRECCA WAHLUND PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3161 43RD ST S
FARGO ND
58104-8791
US

IV. Provider business mailing address

3161 43RD ST S
FARGO ND
58104-8791
US

V. Phone/Fax

Practice location:
  • Phone: 701-893-2639
  • Fax: 701-893-2638
Mailing address:
  • Phone: 701-893-2639
  • Fax: 701-893-2638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2390
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: