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General NPI Number Information
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NPI Number | 1235668427
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Entity Type | Individual
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Provider Name | HOLLIS WUNDERLICH LPCC
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Gender | Female
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Dates
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Enumeration Date | 06/09/2017
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Last Update Date | 01/04/2019
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Provider Practice Location Address
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Address Line | 122 CENTRAL AVE N
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City | FARIBAULT
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State | MN
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Zip | 55021
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Country | US
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Telephone | 507-491-4848
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Fax | 507-323-8141
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Provider Business Mailing Address
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Address Line | PO BOX 431
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City | FARIBAULT
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State | MN
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Zip | 55021-0431
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Country | US
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Telephone |
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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 | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | CC01537
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | CC01537
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License Number State | MN
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