Provider Demographics
NPI:1679693774
Name:WIEGLENDA, JOHN (LAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WIEGLENDA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W VILLARD ST STE B
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5152
Mailing Address - Country:US
Mailing Address - Phone:701-483-0795
Mailing Address - Fax:701-483-0947
Practice Address - Street 1:24 W VILLARD ST STE B
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601
Practice Address - Country:US
Practice Address - Phone:701-483-0795
Practice Address - Fax:701-483-0947
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2018-06-18
Deactivation Date:2018-03-27
Deactivation Code:
Reactivation Date:2018-05-01
Provider Licenses
StateLicense IDTaxonomies
ND1353101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1473810Medicaid
ND11608OtherBCBS