Provider Demographics
NPI:1679664254
Name:WOLFRAM ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:WOLFRAM ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOLFRAM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:320-420-1146
Mailing Address - Street 1:5709 MEADOWLARK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-0737
Mailing Address - Country:US
Mailing Address - Phone:320-420-1146
Mailing Address - Fax:320-258-4380
Practice Address - Street 1:2700 1ST ST N
Practice Address - Street 2:SUITE 209
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4256
Practice Address - Country:US
Practice Address - Phone:320-420-1146
Practice Address - Fax:320-258-4380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3758103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6102104OtherUNITED BEHAVIORAL HEALTH
1014973OtherPREFERREDONE
101219OtherHEALTH PARTNERS
71Q68WOOtherBLUECROSS BLUESHIELD
71Q69WOOtherBLUECROSS BLUESHIELD
MN174708800Medicaid
1014973OtherPREFERREDONE
MN174708800Medicaid