Provider Demographics
NPI:1053043380
Name:WOLGEMUTH, GRACE MARIE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MARIE
Last Name:WOLGEMUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4038 RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2922
Mailing Address - Country:US
Mailing Address - Phone:612-916-4338
Mailing Address - Fax:
Practice Address - Street 1:10273 YELLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9144
Practice Address - Country:US
Practice Address - Phone:952-401-9359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician