Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | LP3703 | MN |
Y | 103T00000X | Psychologist | LP3703 | MN |
NPI | 1013015940 |
---|---|
Provider Name | Lori Ab Wiggenhorn |
First Address | Vadnais Heights, MN 55110-4184 |
Second Address | Vadnais Heights, MN 55110-4184 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2006 |
Last Update Date | 19/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200731439 | (05) | MN |