Provider Demographics
NPI:1952077901
Name:HALVORSEN, WADE DANIEL
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:DANIEL
Last Name:HALVORSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2018
Mailing Address - Country:US
Mailing Address - Phone:952-797-2457
Mailing Address - Fax:
Practice Address - Street 1:923 HALE LAKE POINTE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9615
Practice Address - Country:US
Practice Address - Phone:218-326-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2707225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant