Provider Demographics
NPI:1720391964
Name:ZIMMERMAN, WAYNE EDWIN (MSLP)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:EDWIN
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:MSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1718
Mailing Address - Country:US
Mailing Address - Phone:320-815-0970
Mailing Address - Fax:
Practice Address - Street 1:432 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1718
Practice Address - Country:US
Practice Address - Phone:320-815-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1321103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling