Randall Dean Wallace, M.S.

Primary specialty

PsychologistTaxonomy code 103T00000X

License

LP0683 Issued in MN

Practice address

133 2ND Ave SW
Cambridge, MN 55008-1552

Phone

(763) 689-9407

Fax

(763) 552-0164

NPI assigned

Oct 3, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Family Based Therapy Associates

  • Mental Health Counselor
  • Coon Rapids, MN
  • NPI 1194762005
  NPD (past) Authorized official
• Family Based Therapy Associates

  • Community/Behavioral Health Agency
  • Chisago City, MN
  • NPI 1891100293
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1689768707",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "199 COON RAPIDS BLVD NW",
            "address_2": "SUITE 306",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "554335831",
            "telephone_number": "763-780-1520",
            "fax_number": "763-780-2114"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "133 2ND AVE SW",
            "city": "CAMBRIDGE",
            "state": "MN",
            "postal_code": "550081552",
            "telephone_number": "763-689-9407",
            "fax_number": "763-552-0164"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "RANDALL",
        "middle_name": "DEAN",
        "name_prefix": "Mr.",
        "credential": "M.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-03",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MN",
            "license": "LP0683",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wal-Mart Stores, Inc.
• Sheena Michelle Waldron
• Walgreen Co
• Walker Methodist Levande LLC
• Daniel Charles Wallace, M.D.
• Walmart Inc.
• Timothy Michael Wendel Jr., NP
• Suzanne Gayle Wenstrom Pocrnich, M.S., L.P.
• Nicole Marie Westensee, ATC
• Westerberg Chiropractic P.a.

• All providers in Cambridge, MN
• Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.