Provider Demographics
NPI:1720382062
Name:MARIKEN WOGSTAD-HANSEN, PHD, LLC
Entity Type:Organization
Organization Name:MARIKEN WOGSTAD-HANSEN, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD, LP, RN, CNS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOGSTAD-HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP, RN, CNS
Authorized Official - Phone:651-603-0540
Mailing Address - Street 1:91 SNELLING AVE N
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6753
Mailing Address - Country:US
Mailing Address - Phone:651-603-0540
Mailing Address - Fax:651-603-0541
Practice Address - Street 1:91 SNELLING AVE N
Practice Address - Street 2:SUITE 230
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6753
Practice Address - Country:US
Practice Address - Phone:651-603-0540
Practice Address - Fax:651-603-0541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty