Provider Demographics
NPI:1649393299
Name:WANGEN, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WANGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N 2ND AVE E
Mailing Address - Street 2:#206
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 N 2ND AVE E
Practice Address - Street 2:#206
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2102
Practice Address - Country:US
Practice Address - Phone:218-727-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0058103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN74890WAOtherBCBSMN
MN6800001746Medicare ID - Type Unspecified