Provider Demographics
NPI:1699413930
Name:WAELCHLI, OLIVIA JACLYN
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JACLYN
Last Name:WAELCHLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 OLD CEDAR AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2401
Mailing Address - Country:US
Mailing Address - Phone:952-854-1800
Mailing Address - Fax:952-854-5502
Practice Address - Street 1:9201 OLD CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2401
Practice Address - Country:US
Practice Address - Phone:952-854-1800
Practice Address - Fax:952-854-5502
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician