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General NPI Number Information
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NPI Number | 1043090822
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Entity Type | Individual
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Provider Name | WAKIYAN PETA LAC
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Gender | Male
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Dates
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Enumeration Date | 09/29/2023
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Last Update Date | 09/29/2023
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Provider Practice Location Address
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Address Line | 24276 166TH ST
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City | EAGLE BUTTE
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State | SD
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Zip | 57625-8141
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Country | US
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Telephone | 605-964-0722
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Fax | 605-964-8905
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Provider Business Mailing Address
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Address Line | PO BOX 83
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City | LANTRY
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State | SD
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Zip | 57636-0083
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Country | US
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Telephone | 605-200-5052
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 7051316
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License Number State | SD
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