Provider Demographics
NPI:1235465410
Name:WETTERSTROM, DARLENE FAYE (LICSW)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:FAYE
Last Name:WETTERSTROM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 PENN AVE S STE 301
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2085
Mailing Address - Country:US
Mailing Address - Phone:651-337-1454
Mailing Address - Fax:
Practice Address - Street 1:6701 PENN AVE S STE 301
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2085
Practice Address - Country:US
Practice Address - Phone:651-337-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8660140-00Medicaid
MN800000455OtherMEDICARE