Provider Demographics
NPI:1326069667
Name:WENSTROM, TIMOTHY A (PSYD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:WENSTROM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1929
Mailing Address - Country:US
Mailing Address - Phone:701-234-4141
Mailing Address - Fax:701-234-4024
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1802
Practice Address - Country:US
Practice Address - Phone:701-234-4086
Practice Address - Fax:701-234-4024
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP44232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12155Medicaid
MN764462100Medicaid
MN764462100Medicaid
ND12155Medicaid