Basic Information
| Provider Information | |||||||||
| NPI: | 1033511720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAHLIN | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
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| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 9TH ST W | ||||||||
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| City: | ADA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565101279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187845000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2014 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 104286 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.