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General NPI Number Information
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NPI Number | 1043561335
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Entity Type | Organization
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Legal Business Name | KEN WADUM, ED.D. LP
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Dates
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Enumeration Date | 09/26/2012
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Last Update Date | 09/26/2012
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Provider Practice Location Address
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Address Line | 1530 GREENVIEW DR SW SUITE 207
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City | ROCHESTER
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State | MN
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Zip | 55902-4286
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Country | US
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Telephone | 507-280-0225
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Fax |
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Provider Business Mailing Address
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Address Line | 1530 GREENVIEW DR SW SUITE 207
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City | ROCHESTER
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State | MN
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Zip | 55902-4286
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Country | US
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Telephone | 507-280-0225
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENNETH CHARLES WADUM
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Credential | ED.D.
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Telephone | 507-280-0225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP2777
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License Number State | MN
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