Provider Demographics
NPI:1689768707
Name:WALLACE, RANDALL DEAN (MS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:DEAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:199 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 306
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5831
Mailing Address - Country:US
Mailing Address - Phone:763-780-1520
Mailing Address - Fax:763-780-2114
Practice Address - Street 1:133 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1552
Practice Address - Country:US
Practice Address - Phone:763-689-9407
Practice Address - Fax:763-552-0164
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP0683103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist