Individual
MR. RANDALL DEAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.S.
Contact information
Practice address
133 2ND AVE SW, CAMBRIDGE, MN 55008-1552
(763) 689-9407
(763) 552-0164
Mailing address
199 COON RAPIDS BLVD NW, SUITE 306, COON RAPIDS, MN 55433-5831
(763) 780-1520
(763) 780-2114
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
LP0683
MN
Other
Enumeration date
10/03/2006
Last updated
07/08/2007
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