Provider Demographics
NPI:1417374067
Name:WALLENBERG, JOANNA (LICSW)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:WALLENBERG
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 1:31795 COUNTY HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-4075
Mailing Address - Country:US
Mailing Address - Phone:218-444-2845
Mailing Address - Fax:218-444-2847
Practice Address - Street 1:514 BELTRAMI AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3010
Practice Address - Country:US
Practice Address - Phone:218-444-2845
Practice Address - Fax:218-444-2847
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN206291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical