Provider Demographics
NPI:1922559186
Name:WANNER, PRESLEY
Entity Type:Individual
Prefix:
First Name:PRESLEY
Middle Name:
Last Name:WANNER
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 1:3060 FRONTIER WAY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8909
Mailing Address - Country:US
Mailing Address - Phone:701-232-2340
Mailing Address - Fax:701-232-2330
Practice Address - Street 1:3401 45TH ST S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8970
Practice Address - Country:US
Practice Address - Phone:701-356-4384
Practice Address - Fax:701-356-4383
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CO1-20-46622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician