Provider Demographics
NPI:1073192068
Name:WALLBERG, CRISTOFER
Entity Type:Individual
Prefix:
First Name:CRISTOFER
Middle Name:
Last Name:WALLBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10450 185TH ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6696
Mailing Address - Country:US
Mailing Address - Phone:952-923-8607
Mailing Address - Fax:
Practice Address - Street 1:10450 185TH ST W STE 100
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6696
Practice Address - Country:US
Practice Address - Phone:612-509-1283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other