Healthcare Provider Details

I. General information

NPI: 1790689552
Provider Name (Legal Business Name): CANDACE MARIE WETTERLUND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S COLUMBIA ROAD BEHAVIORAL HEALTH - CREDITIALING DEPARTMENT
GRAND FORKS ND
58201
US

IV. Provider business mailing address

315 N WEST AVE
WARREN MN
56762-1000
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax:
Mailing address:
  • Phone: 208-305-2640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR39147
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: