Provider Demographics
NPI:1295060614
Name:TODD M WAHL PSYD LLC
Entity type:Organization
Organization Name:TODD M WAHL PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:970-581-9398
Mailing Address - Street 1:PO BOX 272716
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-2716
Mailing Address - Country:US
Mailing Address - Phone:970-581-9398
Mailing Address - Fax:877-838-8925
Practice Address - Street 1:2315 DUNN AVE # 6
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3214
Practice Address - Country:US
Practice Address - Phone:970-581-9398
Practice Address - Fax:877-838-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-03
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3094103TC0700X
WY444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty