| Doctor Name: | GARY A WALLINGA |
| NPI Number: | 1043260110 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PHD LP |
| License Number: | LP2053 |
| Business Practice Address: | 1900 Centracare Cir Suite 1325 Saint Cloud, MN - 563035000 |
| Business Phone Number: | 3202555796 |
| Business Fax Number: | 3202295179 |
| Mailing Address: | 1406 6th Ave N, SAINT CLOUD |
| State: | MN |
| Postal Code: | 563031900 |
| Phone Number: | 3202512700 |
| Fax Number: | 3206567026 |
| NPI Enumeration Date: | 05/11/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC2200X |
| License Number: | LP2053 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical Child & Adolescent |
| Taxonomy Definition: | |