Provider Demographics
NPI:1891221826
Name:WACHLIN, MARK (LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WACHLIN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-4685
Mailing Address - Country:US
Mailing Address - Phone:507-434-1903
Mailing Address - Fax:507-434-1833
Practice Address - Street 1:101 14TH ST NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-4685
Practice Address - Country:US
Practice Address - Phone:507-434-1903
Practice Address - Fax:507-434-1833
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303155101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)