Provider Demographics
NPI:1356554000
Name:WAHL, TODD (PSYD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:WAHL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 XAVIER ST APT 217
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1413
Mailing Address - Country:US
Mailing Address - Phone:701-415-8271
Mailing Address - Fax:
Practice Address - Street 1:4719 SHELBURNE ST STE 11
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5677
Practice Address - Country:US
Practice Address - Phone:701-415-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY444103TC0700X
CO3094103TC0700X
MN6144103TC0700X
ND563P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical