Provider Demographics
NPI:1083689624
Name:WANDERSEE, RICHARD ALAN (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:WANDERSEE
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:11475 ROBINSON DR NW
Practice Address - Street 2:MAIL STOP 32600A
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3746
Practice Address - Country:US
Practice Address - Phone:763-754-4600
Practice Address - Fax:763-754-4614
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN015931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R76972Medicare UPIN