Basic Information
| Provider Information | |||||||||
| NPI: | 1093757205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEDIN-GORDEN | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW,LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1237 W DIVIDE AVE | ||||||||
| Address2: | STE 5 | ||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585011290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013288832 | ||||||||
| FaxNumber: | 7013288900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1237 W DIVIDE AVE | ||||||||
| Address2: | STE 5 | ||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585011290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013288832 | ||||||||
| FaxNumber: | 7013288900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YA0400X | 1526 | ND | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 2031 | ND | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | N21925 | 01 | RR MEDICARE PIN | OTHER | 021925 | 01 | BCBS OF ND PIN | OTHER |