Provider Demographics
NPI:1013015940
Name:WIGGENHORN, LORI AB (MA, LP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:AB
Last Name:WIGGENHORN
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 TALMAGE CIR STE 205
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4184
Mailing Address - Country:US
Mailing Address - Phone:612-388-5236
Mailing Address - Fax:612-326-3359
Practice Address - Street 1:3640 TALMAGE CIR STE 205
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-4184
Practice Address - Country:US
Practice Address - Phone:612-388-5236
Practice Address - Fax:612-326-3359
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3703103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN200731439Medicaid
MN030916800Medicare ID - Type UnspecifiedMEDICAL ASSISTANCE